The Fraud Examiner

HOOKED ON FRAUD: ANNUAL CONFERENCE SPEAKERS RECALL THE CASES THAT SPARKED THEIR CAREERS IN FRAUD INVESTIGATION

Jennifer Liebman  
Research Editor, Association of Certified Fraud Examiners

Many of the fraud-fighting heroes who will come together this June in Nashville, Tennessee, for the ACFE Global Fraud Conference are at the top of their careers. But fraud fighters aren’t just born with a sixth sense for schemes. Even heroes must learn what it takes to combat fraud. We talked to a few of this year’s conference speakers about the early cases that left an impression on them and taught them the essentials of fighting fraud. Through these cases they developed persistence, had their lives changed and learned the importance of counting cattle in West Texas.

Never Mind the Road Blocks

For Tom Caulfield, CFE, chief operating officer of Procurement Integrity Consulting Services, the case that left a memorable impression on him wasn’t his first, but rather the one that showed him not everyone will be as cooperative or as gung ho about pursuing a case as you’d like. As Caulfield, who has more than 38 years of government and fraud-fighting experience relates, “Persistence and tenacity were keys to this case. CFEs need to balance their desire to find out the truth with sound investigative techniques and being obsessed with obtaining a conviction.”

In 1997, Caulfield was the deputy chief of investigation for the U.S. National Reconnaissance Office of the Inspector General (OIG), when he worked on a case concerning proprietary information of a government contractor. The thief used a lunch date with former co-workers to steal data from his old company. While waiting for his colleagues in an empty office, he discovered that the company never deleted his computer password. So he helped himself to the government contracting and engineering information to bolster his job marketability.

But the staff of the government program with whom the victim company was doing business weren’t all that interested in the data theft allegations — they did not want any bad attention. Frustrated, the victim company turned to the OIG for help, and Caulfield and his team pursued the case as a violation of the Procurement Integrity Act.  

 “The government program people showed no concern with the government engineering data being stolen as they claimed they would have shared it with anyone requesting it, including the company the subject went to work for. As for the stolen government contracting data, the program people again felt it had no value for future competitive advantages,” Caulfield said. “Throughout the investigation the government program people continuously created road blocks for the investigation. They went on record with the subject’s legal counsel and told them the government engineering data was not stolen as they would have provided it to anyone who wanted it.” While the information might have technically been available to someone who legitimately requested it through the Freedom of Information Act, Caulfield points out that the information was not requested — it was taken without consent.

Eventually, the thief was convicted, but not for stealing the information. He was convicted for submitting false claims to the government. During the investigation, Caulfield and his team came across receipts and records that showed that the subject had masked a trip to a job interview by telling his employer that the government had requested that he travel from Texas to Virginia and then submitting the travel expenses to the government contractor who in turn included the expenses in its cost reimbursement to the government.

Caulfield credits the victim organization for seeing the case through to the end. “The investigation was a partnership and could not have been successful without them,” he said. “They were being pressured by the government program people to discontinue the complaint. They stood strong with us knowing they could have lost contracting opportunities with the government program department.”

Fraud is Everywhere…and it’s Personal

Since starting her career in the mid-1990s, health care compliance consultant Jacqueline Bloink, CFE, says she has seen all sorts of health care fraud, including up-coding schemes, unbundling schemes, provider-ID misuse, fake credentials, billing for services never rendered, overbilling, keeping overpayments from Medicare and Medicaid, and doctor shopping for pain medication. Bloink said, “So many schemes, too many to list!”

Bloink’s first brush with fraud happened early on as a medical practice administrator. One of the physicians in the practice shared with her that his ex-wife had been caught stealing from the practice. The ex-wife had been keeping cash co-pays and then adjusting the books accordingly. This showed her just how commonplace fraud is. It was also an ACFE Report to the Nations stat come to life. “Fraud happens in good companies…and in good families. It is so interesting to read the Report to the Nations to look at the statistics on who — age, gender, financial status — is involved in fraudulent schemes,” she said.  

While Bloink would go on to investigate health care fraud in all its iterations, the biggest fraud case she worked on was also the largest False Claims Act case in Arizona history. Bloink uncovered the fraud in just her first five months on the job as an internal auditor for a hospital network in Arizona. As she prepared for her audit, she researched all the appropriate regulations and guidelines. When she conducted the audit, she found billing disparities for patients enrolled in federal government programs such as Medicare and Medicaid. She reviewed the previous auditor’s report and found that it too had problems. Bloink soon learned just how personal fraud investigating can get. “Retaliation toward me started the very afternoon after my final audit results were turned in,” she said.

Ultimately, the health network had to pay $35 million in fines for engaging in fraudulent billing and concealing its obligations. Even though Bloink has been heralded for her role as a whistleblower in the case, it hasn’t been easy. “Fraud is very emotional … It is not just financial — it ruins many lives. My life was changed forever by the case.”

But Bloink is staying vigilant against fraud despite the challenges. “I told Tucson in an open letter to the community that I would not go underground, but continue to fight health care fraud,” she said.“The case showed me just how pervasive health care fraud is. Many professionals in health care know fraud is occurring but feel it is okay because the reimbursement is low, or they justify it for a million other reasons. Providers and CEOs don’t think they will get caught, or that co-workers won’t turn them in. And many times, they are right.”