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CASE STUDY: MORAL HAZARD IN
INSURANCE
HEALTHCARE PROVIDER FRAUD
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Marijana Ćurak - University of Split, Faculty of Economics
Academic year 2014/2015
10/22/2014
International Week – New Frontiers in Finance and Accounting 2014
University of Economics in Katowice
These lecture slides are based on the book:
Hymes, L. and Walls, J. T. (2013): Insurance Fraud
Casebook: Paying a Premium for Crime, Wiley
10/22/2014
Marijana Ćurak - University of Split, Faculty of Economics
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AGENDA
Frauds
Case study - healthcare provider fraud: Doctor
submits $500,000 in false claims
Note: This case is taken from: Hymes, L. and Walls,
J. T. (2013): Insurance Fraud Casebook: Paying a
Premium for Crime, Wiley
Marijana Ćurak - University of Split, Faculty of Economics
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DEFINITION OF FRAUD (1)
According to Sharma, fraud is:
A dishonest act and behavior by which one person
gains or intends to gain an advantage over
another person
The gain may accrue to the person himself or to
someone else
Marijana Ćurak - University of Split, Faculty of Economics
DEFINITION OF FRAUD (3)
According to the American Institute of Certified Public
Accountants fraud is:
A broad legal concept that is distinguished from error
depending on whether the action is intentional or
unintentional
Marijana Ćurak - University of Split, Faculty of Economics
EXAMPE – OVERCHARGE FOR DAMAGE
REPAIR
A report published by the California Bureau of
Automotive Repair in 2002 indicated that of over 500
vehicles inspected after repairs, more than 40% of the
bills included charges for work never done or for parts
not used
The average overcharge was $586 (one-sixth of the
average auto insurance claim after an accident)
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Marijana Ćurak - University of Split, Faculty of Economics
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FRAUDS BY PERPETRATORS
Internal frauds (Occupational frauds) - schemes in which
an employee abuses the trust placed in him or her by an
employer for personal gain
External frauds - schemes against financial institutions,
perpetrated by outside subjects
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Marijana Ćurak - University of Split, Faculty of Economics
POLICYHOLEDER AND CLAIM FRAUD (1)
Problem related to both – information
asymmetry ex-ante (adverse selection) and ex-
post (moral hazard)
Can be committed by policyholders
at inception of the insurance contract
during the insurance contract
when claiming payment or compensation
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Marijana Ćurak - University of Split, Faculty of Economics
POLICYHOLDER AND CLAIM FRAUD (2)
Claim fraud can also be committed by third
parties involved in the settlement of a claim
For example: engineers could inflate the cost of
repairs or medical practitioners could claim for
medical services which have not been provided
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THE CASE STUDY
Dr. Susan Shamrock wanted to give a non-
approved, experimental allergy treatment to her
suffering patients
Unfortunately, she overcharged for the drug in
the amount of about a half a million dollars
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THE BEGINNING (1)
Susan Shamrock became a doctor because she wanted
to provide people with relief from their allergy suffering
She enjoyed being a doctor and helping people
Dr. Shamrock was highly respected in her community
and she gave generously to various local charities
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THE BEGINNING (2)
As the years passed, both Susan and her husband took
to gambling at local casinos for entertainment
Eventually, Mr. Shamrock quit his job to pursue
professional gambling
Susan’s husband lost a lot of their money gambling
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A GROWING COMPANY
After Susan opened her own allergy clinic
Business was so good that she hired employees to
schedule appointments, handle accounts payable and
receivable and file claim forms with insurance companies
and federal and state healthcare programs
She also hired medical assistants and an office manager
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EXPERIMENTAL ALLERGY TREATMENT (1)
Sometimes Susan became frustrated because a few of
her patients didn’t respond to treatment regimens
As part of her continuing education, Susan attended
various seminars where she learned from other experts
in the field
At one training event, the speaker discussed a new
allergy treatment that was considered experimental by
the Food and Drug Administration (FDA)
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EXPERIMENTAL ALLERGY TREATMENT (2)
Susan was inspired by the presentation and immediately
began offering the treatment as an alternative to her
patients who hadn’t responded to previous therapy
She even listed the experimental treatment on her
website
Several of her patients were willing to try it out of
frustration because nothing else worked for them, and
they had no doubt because their insurance paid for it
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THE CASE (1)
Charles Piper, CFE, received a referral
The note indicated that Dr. Susan Shamrock had
possibly miscoded billings for allergy treatments when
submitting claims for several of her patients
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THE CASE (1)
She provided patients with nonapproved, experimental
allergy treatment but listed it on insurance claims as a
different, approved treatment
During a federal audit of a random sampling of billed
treatments, Dr. Shamrock was asked to provide
supportive documentation for several of the insurance
claims she submitted and that the government already
had processed and paid
However, Dr. Shamrock ignored or failed to respond to
the requests
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THE INVESTIGATION (1)
The investigators separately requested and later
obtained copies of numerous patient files and billing
records from the doctor’s office
When they received the records, they reviewed them
They searched for indicators that patients received the
experimental treatment, which may have been miscoded
and billed as an FDA‐approved treatment
The review took several weeks to complete
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THE INVESTIGATION (2)
They found repeated instances where there was
absolutely no supportive documentation for any of the
services billed for
The written notes in the patients’ files contradicted the
insurance claims
The charts were incriminating evidence that the patient
had not visited Dr. Shamrock nearly as frequently as the
documents indicated
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THE INVESTIGATION (3)
The investigators began to understand why Dr.
Shamrock refused to comply with the auditors’ previous
request for treatment records - she didn’t have any to
give!
Knowing that documents alone do not prove a case, the
investigators began interviews of patients at their homes
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THE INTERVIEWS (1)
Their first interview was of a former patient named
Steve Hardwick
He said he never received more than two or three
injections in any given week
But what Hardwick said next was a complete surprise: “I
didn’t need to go to the doctor’s office anyway; Dr.
Shamrock just gave me the filled syringes to inject
myself.”
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THE INTERVIEWS (2)
He injected himself only two or three times each week,
not four or five times like the insurance claims indicated
Plus, the insurance claims specifically listed the location
of service as Dr. Shamrock’s office
The investigators conducted more patient interviews
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THE INTERVIEWS (3)
A few people also said they received an experimental
allergy treatment
Those patients reported that Dr. Shamrock assured them
she would take care of the insurance billings
Since the patients didn’t have to pay any money out of
pocket, they had no concerns about how much the
insurers were billed or how the treatments were coded
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FURTHER INVESTIGATION (1)
The investigators contacted one of the government
healthcare program integrity officials and were informed
that each injection should have been given by a qualified
and approved healthcare professional inside the
physician’s office
The official said the patients should have been
monitored by a healthcare professional in case they had
adverse reactions to the injections
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FURTHER INVESTIGATION (2)
The investigator were also informed that the government
would not have paid those claims had they known the
patients injected themselves and that the locations of
service were falsely recorded
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FURTHER INVESTIGATION (3)
In addition to billing for injections, Dr. Shamrock billed
extremely high prices for “preparing and mixing” the
antigens in the syringes
Injections were billed at about $50 each, but mixtures
were billed for thousands of dollars each!
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FURTHER INVESTIGATION (4)
The real money Dr. Shamrock made came from the
falsification in the number of antigen mixtures made
To avoid detection, she billed for lots of injections — and
made an extra $50 for each fictitious injection
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FURTHER INVESTIGATION (5)
The insurance regulations required patients to pay
copayments when they received treatment
Providers are not permitted to deny the copayments
Dr. Shamrock had no qualms submitting false claims to
insurance companies, but she never sent her patients
false bills for the copayments
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Marijana Ćurak - University of Split, Faculty of Economics
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FURTHER INVESTIGATION (6)
The investigators also asked for the doctor’s office
appointment and sign‐in books and found that the
patients who were billed as if treated on certain dates
did not have appointments and did not sign in on those
dates
Additionally, they interviewed former and current
employees
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THE INTERVIEW WITH THE FORMER
AND CURRENT EMPLOYEES (1)
One of the former administrative employees told: “A
few years ago we got into trouble with an insurance
company for not having supportive documentation,
and I told Dr. Shamrock to stop billing for services
that we hadn’t provided. But she wouldn’t listen to
me and we kept on doing it.”
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THE INTERVIEW WITH THE FORMER
AND CURRENT EMPLOYEES (2)
The investigators also interviewed Dr. Shamrock’s
current office manager, Katy Lincoln, at her home on a
weeknight
She essentially said the same thing as the former
employee
The investigators decided to try to get additional
evidence and asked Katy if she would consent to record
a telephone conversation with Dr. Shamrock
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Marijana Ćurak - University of Split, Faculty of Economics
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THE TELEPHONE CONVERSATION
In the recorded conversation, Dr. Shamrock said she
knew miscoding the treatments was not appropriate
She also admitted she knew the doctor’s office was
sometimes paid for treatments not provided
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THE TALK TO DR SHAMROCK (1)
When the investigator asked Dr. Shamrock about the
missing documentation to support the billings, she
blamed an office flood
When he asked why she let patients inject themselves
away from the office, she said they preferred it that way
When he asked how she determined the dates that
injections were given, she initially said she just guessed
but later said the office computer automatically entered
the dates
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THE TALK TO DR SHAMROCK (2)
When he asked why she didn’t collect copayments from
her patients when they were treated, she said her
patients couldn’t afford to make the copayments
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THE END (1)
The invstigators brought their collective case to the
prosecutor’s office
In total, the losses were approximately $500,000
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Marijana Ćurak - University of Split, Faculty of Economics
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THE END (2)
She paid for the losses
Rather than suspending Dr. Shamrock from doing future
business with the government, the affected agencies
decided to put her on a well‐monitored performance and
compliance plan, which subjected her to regular audits
to ensure that this type of activity would not occur in the
future
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REFERENCES (1)
Goldmann, P. D. (2010), Financial Services Anti-Fraud
Risk and Control Workbook, John Wiley & Sons, Inc.
Hymes, L. and Walls, J. T. (2013): Insurance Fraud
Casebook: Paying a Premium for Crime, Wiley
IAIS, (2007), Report on Preventing, Detecting and
Remedying Fraud in Insurance
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REFERENCES (2)
IAIS, (2011), Application Paper on Deterring, Preventing
Detecting, Reporting and Remedying Fraud in Insurance
Sharma, B. R. (2011), Bank Frauds – Prevention &
Detection, Universal Law Publishing Co.
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