Beyond the Allegation · GlaxoSmithKline settles health care fraud case for $3 billion 17 Accused of Medicare Fraud – Physician and pharmacist bilking Medicare/Medicaid on elaborate
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Beyond the Allegation:A Guide for Conducting Internal Investigations
Barbara Naimark, Director, National Special Investigations Unit & FWA Training
Although the legal definition of fraud is very specific, for most people — anti-fraud professionals, regulators, the media, and the general public alike —the common usage is much broader and generally covers any attempt to deceive another party to gain a benefit.
Health care fraud, identity theft, padded expense reports, mortgage fraud, theft of inventory by employees, manipulated financial statements, insider trading, Ponzi schemes — the range of possible fraud schemes is large, but at their core, all of these acts involve a violation of trust.
It is this violation, perhaps even more than the resulting financial loss, that makes such crimes so harmful*.
*National Association of Certified Fraud Examiners 2012 – Report to the Nations
WHO? •Who is the subject of the investigation?•Who are the witnesses? Reporting Party or complainant?•Who is the victim? Do we have a victim? Is the victim an entity or a person?
WHAT? •What is alleged? •Does the investigation uncover new allegations?•What policy, procedure, rule, regulation, or law is violated?•What documents might be involved?•What happened?
WHEN? •When did this allegation occur?•When did subject / witnesses / entity obtain a particular document or item?
•When did a policy, procedure, rule, etc. become effective?•When did you as an investigator conduct interviews or obtain documents?
•WHERE? •Where did this allegation occur?•Where are the documents used to perpetrate the violation?•Where is the subject or witness/es located?•Where is evidence held?•Where were interviews held?
•WHY? •Why did the subject do what they did? (Motive)•Why is the reporting party making the complaint?
•HoW? •How did the violation or problem occur?• Is there documentation to support how this activity occurred?•Are there gaps in current processes?
Initiating an Investigation Plan What are the allegations?
– Clear allegation?
– Does the investigation lead to other allegations?
What policies / procedures have been violated?
What regulations / laws may have been violated?
Who else should be on an investigative team?– Auditors
– Information Technology / Computer Forensics
– Legal
– Other Compliance
Are others already conducting an investigation? Previous investigation?
HIPAA and state laws require that patient identifiable medical records or protected health information be maintained confidentially. There are limited exceptions for disclosure in certain types of investigations.
Conducting Interviews
Preparation– Review all pertinent documentation and records pertaining to allegations
Who are you interviewing– Victim, witness, subject/suspect
Patience– Allow a enough time
Persistence– Questions to obtain full and consistent statement
Check your own company policy and legal departments on confidentiality advisements.
National Labor Relations Board has recent rulings on confidentiality advisements related to represented employees.
Represented employees are generally allowed union representation if they are the subject of the investigation and the investigation could lead to disciplinary action.
Tell the story of what happened. Create a simple but clear mental picture so the reader can understand what happened.
Everyone relies on what you have written in your report.
EYA(Explain Your Acronyms)
Chronological Order
Chronological order is order by time. Your report should tell what happened in the order that the events took place.
Get all the facts and then list them in the order in which they happened. It is much easier to understand what happened if the details are written in chronological order, even if the people involved do not tell you the information in chronological order.