Advanced Fraud Analysis

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Description

Case study: Analytical Review of Armenian Healthcare Fraud Case

Subject: Economics

Analytical Review of Armenian Healthcare Fraud Case

Your final paper will be related to an Armenian Medicaid Fraud Indictment.  See below for a PDF Version of the Indictment:

Here is some high-level background on the indictment:

A group of Armenian Fraudsters allegedly stole doctors’ identities and used the information to enroll the phantom physicians as providers in Medicare.

Authorities began the New York-based investigation after information on 2,900 Medicare patients in upstate New York — including Social Security numbers and dates of birth — were reported stolen.

The defendants in the New York case also allegedly had stolen the identities of doctors and set up 118 phantom clinics in 25 states, authorities said. The names were used to submit fake bills for care that was never given.

Some of the phony paperwork was a giveaway: It showed eye doctors doing bladder tests; ear, nose and throat specialists performing pregnancy ultrasounds; obstetricians testing for skin allergies; and dermatologists billing for heart exams.

In your expert opinion, how can this DATA be used to identify this type of fraud earlier in the detection cycle to prevent cases from growing this large in the future

Note– Dr specialty code with procedure code link ???

One official said that they were aware that each clinic had a limited shelf life and would simply turn to another fraudulent clinic — they existed only on paper with an address that was usually a mail drop —

Note: What data could you use for this – address against mail drop data base?   Think of the tools discussed in our readings (data tools discussed in chapters 1,2,3, and 5 – Data Mining for Intelligence, Fraud & Criminal Detection Advanced Analytics & Information Sharing Technologies; Christopher Westphal ** let me know if you have an access to some kind of a library where you can find this book).

Assignment

You are the Assistant Director for the __fake state__ Insurance Fraud Bureau and you have been contacted regarding this case.  Your assignment is to review this indictment and provide an executive briefing of the case for your director and your team.

Please write a detailed Case briefing between 5-10 pages long using the criteria listed below:

  1. A detailed Executive case briefing including an executive summary of the case:
    1. Cover page with your name, contact information including phone number along with assignment information
    2. Page 1 MUST include a full 1 page executive summary encapsulating the entire paper
    3. Pages 2-10 should showcase your complete review and assessment including how you plan to study this case and future cases which are similar in nature, to foster more pro-active detection in the future.  Ensure you provide your overall fraud detection plan in this section (please do not try and boil the ocean… in other words, stay focused and on topic).   Example items for you to consider in the section include but should not be limited to:
  1. Proposed data categories you will have your staff analyze to detect this type of activity (examples):
    -clinic address matches to PO Box addresses
    -Dr speciality vs diagnostic program
    -Key contact names for each clinic/addresses
    -Stolen identities vs. claims :utilize dates such as date of identity stolen vs date of claim
    1. Link Diagrams – Within the paper, you must showcase your findings graphically to show linkages between the case elements in the indictment and via the WWW.   At a minimum, you have been provided with several SMALL datasets within the indictment that can be leveraged to show linkage by state and other attributes.   Please showcase your ability to create a well thought out analytical diagram within your paper, supported by your annotated findings.
  1. Analytical recommendations for studying, detecting and mitigating this type of fraud in the future.  You may recommend technical approaches from the Westphal book or other readings.

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