Tag Archives: ACAMS

Using Link Analysis to untangle fraud webs

Posted by Douglas Wood, Editor.

NOTE: This article originally appeared HERE by Jane Antonio. I think it’s a great read…

Link analysis has become an important technique for discovering hidden relationships involved in healthcare fraud. An excellent online source, FierceHealthPayer:AntiFraud, recently spoke to Vincent Boyd Bryant about the value of this tool for payer special investigations units.

A former biometric scientist for the U.S. Department of Defense, Bryant has 30 years of experience in law enforcement and intelligence analysis. He’s an internationally-experienced investigations and forensics expert who’s worked for a leading health insurer on government business fraud and abuse cases.

How does interactive link analysis help insurers prevent healthcare fraud? Can you share an example of how the tool works?

Boyd Bryant: Link analysis is most often used to piece together different kinds of data from multiple sources–to identify key players, connections between those players and patterns of behavior frequently missed. It can simplify an understanding of the level of involvement of individuals and criminal organizational hierarchies and can greatly simplify visualizing and communicating the operations of complex criminal enterprises.

One thing criminals do best is hide pots of money in different places. As a small criminal operation becomes successful, it will often expand its revenue streams through associated businesses. Link analysis is about trying to figure out where all those different baskets of revenue may be. Insurers are drowning in a sea of theft. Here’s where link analysis becomes beneficial. Once insurers discover a small basket of money lost to a criminal enterprise, then serious research needs to go into finding out who owns the company, who they’re associated with, what kinds of business they’re doing and if there are claims associated with it.

You may find a clinic, for example, connected to and working near a pharmacy, a medical equipment supplier, a home healthcare services provider and a construction company. Diving into those companies and what they do, you find that they’re serving older patients for whom multiple claims from many providers exist. The construction company may be building wheelchair ramps on homes. And you may find that the providers are claiming payment for dead people. Overall, using this tool requires significant curiosity and a willingness to look beyond the obvious.

Any investigation consists of aggregating facts, generating impressions and creating a theory about what happened. Then you work to confirm or disconfirm your theory. It’s important to have tools that let you take large masses of facts and visualize them in ways that cue you to look closer.

Let’s say you investigate a large medical practice and interview “Doctor Jones.” The day after the interview, you learn through link analysis that he transferred $11 million from his primary bank account to the Cayman Islands. And in looking at Dr. Jones’ phone records, you see he called six people, each of whom was the head of another individual practice on whose board Dr. Jones sits. Now the investigation expands, since the timing of those phone calls was contemporaneous to the money taking flight.

Why are tight clusters of similar entities possible indicators of fraud, waste or abuse?

Bryant: When you find a business engaged in dishonest practices and see its different relationships with providers working out of the same building, this gives rise to reasonable suspicion. The case merits a closer look. Examining claims and talking to members served by those companies will give you an indication of how legitimate the operation is.

What are the advantages of link analysis to payer special investigation units, and how are SIUs using its results?

Bryant:  Link analysis can define relationships through data insurers haven’t always had, data that traditionally belonged to law enforcement.

Link analysis results in a visual reference that can take many forms: It can look like a family tree, an organizational chart or a time line. This reference helps investigators assess large masses of data for clustering and helps them arrive at a conclusion more rapidly.

Using link analysis, an investigator can dump in large amounts of data–such as patient lists from multiple practices–and see who’s serving the same patient. This can identify those who doctor shop for pain medication, for example. Link analysis can chart where this person was and when, showing the total amount of medication prescribed and giving you an idea of how the person is operating.

What types of data does link analysis integrate?

Bryant: Any type of data that can be sorted and tied together can be loaded into the tool. Examples include telephone records, addresses, vehicle information, corporate records that list individuals serving on boards and banking and financial information. Larger supporting documents can be loaded and linked to the charts, making cases easier to present to a jury.

Linked analysis can pull in data from state government agencies, county tax records or police records from state departments of correction and make those available in one bucket. In most cases, this is more efficient than the hours of labor needed to dig up these types of public records through site visits.

Is there anything else payers should know about link analysis that wasn’t covered in the above questions?

Bryant: The critical thing is remembering that you don’t know what you don’t know. If a provider or member is stealing from the plan in what looks like dribs and drabs, insurers may never discover the true extent of the losses. But if–as a part of any fraud allegation that arises–you look at what and who is associated with the subject of the complaint, what started as a $100,000 questionable claims allegation can expose millions of dollars in inappropriate billings spread across different entities.

Perhaps a nice change at NICE Actimize?

Posted by Douglas Wood, Editor.  http://www.linkedin.com/in/dougwood

Though not publicly released, news out of NICE Actimize is that long-time CEO Amir Orad is leaving the company effective May 1. Indicative of the ‘what a small world this is’ nature of the financial crimes technology marketplace, former Pegasystems co-founder and head of Americas for BAE Systems Detica, Joe Friscia, will be taking over the helm at that time.

Mr. Orad led NICE Actimize’s product and strategy functions prior to his five year tenure as CEO. During his tenure, he scaled the business size over six-fold. He is also a founding board member at BillGuard the venture backed personal finance analytics and security mobile app company.

Prior to Actimize, Orad was co-founder and CMO of Cyota a cyber security and payment fraud cloud company protecting over 100 million online users, acquired by RSA Security for $145M. Following the acquisition, he was VP Marketing at RSA.

I’ve known both Amir and Joe for several years, and have a tremendous amount of respect for both gentlemen. While it’s sad to see Amir leave the organization, I know that his rather large shoes will be more than adequately filled by Mr. Friscia.

Joe’s background is well-suited to this new position, and all of us here at FightFinancialCrimes wish him well. Joe joined Detica when BAE Systems acquired Norkom Technologies in early 2011, where he served as General Manager and Executive Vice President of the Americas. Joe led the rapid growth of Norkom in the Americas, with direct responsibility for sales, revenue and profit as well as managing multi-discipline teams based in North America. Prior to Norkom, Joe helped start Pegasystems Inc in 1984, a successful Business Process Management software company that went public in 1996.

Best of luck to Amir in his new ventures, and to Joe as he guides Actimize into it’s next phase.

Part 2: Investigating the Investigations – X Marks the Spot

Posted by Douglas Wood, Editor.  http://www.linkedin.com/in/dougwood

Part One of this series is HERE.

Most of the financial crimes investigators I know live in a world where they dream of moving things from their Inbox to their Outbox. Oh, like everyone else, they also dream about winning the lottery, flying without wings, and being naked in public. But in terms of the important roles they perform within both public and private sectors, there is simply Investigating (Inbox) and Adjudication (Outbox). Getting there requires a unique blend of their own capabilities, the availability of data, and the technology that allows them to operate. In the diagram below, ‘X‘ marks the spot where crimes are moved from the Inbox to the Outbox. Without any of those three components, an investigation becomes exponentially more difficult to conclude.

Presentation1

In part one of this article two weeks ago, I wrote about the Investigation Management & Adjudication (IMA) side of financial crimes investigations. I coined that term to call out what is arguably the most integral component of any enterprise fraud management (EFM) ecosystem. The original EFM overview is here.

   “The job is almost unrecognizable to those who once used rotary phones in smoke filled offices…

Twenty years ago, IMA was based primarily upon human eyes. Yes, there were technology tools available such as Wordperfect charts and Lotus 1-2-3 spreadsheets, but ultimately it was the investigator who was tasked with finding interesting connections across an array of data elements including handwritten briefs, telephone bills, lists of suspect information, and discussions with other investigators. The job got done, though. Things moved from the Inbox to the Outbox, arrests were made and prosecutions were successful. Kudos, therefore, to all of the investigators who worked in this environment.

Fast forward to today, and the investigator’s world is dramatically different. The job is the same, of course, but the tools and mass availability of data has made the job almost unrecognizable to those who once used rotary phones in smoke filled offices. Organizations began building enterprise data warehouses designed to provide a single version of the truth. Identity Resolution technology was implemented to help investigators recognize similarities between entities in that data warehouse. And today, powerful new IMA tools are allowing easy ingestion of that data, improved methods for securely sharing across jurisdictions, automated link discovery, non-obvious relationship detection, and interactive visualization tools, and -importantly – packaged e-briefs which can be understood and used by law enforcement, prosecutors, or adjudication experts.

     “Without any of these components, everything risks falling to the outhouse…

With all these new technologies, surely the job of the Investigator is becoming easier? Not so fast.

IMA tools – and other EFM tools – do nothing by themselves. The data – big data – does nothing by itself. It just sits there. The best investigators – without tools or data – are rendered impotent.  Only the combination of skilled, trained investigators using the best IMA tools to analyze the most useful data available results in moving things from the Inbox to the Outbox. Without any of these components… everything eventually risks falling to the Outhouse.

Kudos again, Mr. and Mrs. Investigator. You’ll always be at the heart of every investigation. Here’s hoping you solve for X every day.

Investigating the Investigations.

Posted by Douglas Wood, Editor.

A few years ago, I read a book called Fraud Analytics by Delena Spann.  Ms. Spann is with the U.S. Secret Service, Electronic & Financial Crimes Task Force. The book is an overview of investigation analytics with specific information about some former technology leaders in this area.

The IBM i2 toolset is discussed, along with offerings from Raytheon, Centrifuge, and SAS, and FMS’ Link Analytics, and others. (My friend Chris Westphal, formerly of Raytheon Visual Analytics, by the way, published his book ‘Data Mining for Intelligence, Fraud & Criminal Detection’ a few years ago and is another one I strongly recommend.)

Both books offer advice and use cases on how technology can be applied in the fight against crime. A few months ago, I summarized the types of technology being put to use as tools to prevent, detect, and investigate fraud and other criminal activities. (It’s worth a quick read.) What I’m investigating today, however, is… well, investigations.

“IMA is the most critical connection between technology and investigators.”

In my technology summary, I termed this area Investigation Management & Adjudication (IMA). IMA is the most critical connection between technology and humans within an enterprise fraud management ecosystem. Incorporating key elements of enterprise case management, collaboration, link visualization, information dissemination and knowledge discovery, this layer of functionality is designed to uncover insights which aid in investigating complex incidents. The result ought to be actionable visualization of critical entities, and documented results for potential litigation and regulatory compliance.

IBM i2 has long been considered a thought and market leader in this segment – deservedly or not. Palantir Technologies plays in this area as well. Perhaps no company is more in tune with this market, though, than Visallo with their leading investigation analytics platform. Each platform clearly adds value to investigation case management solutions by providing powerful, emerging functionalities that allow easy and intuitive consumption of data in any form. For investigators, the more data – and the easier that data is to consume – the better.

“Users want actionable intelligence, not endless queries.”

What makes for good IMA? A few things, actually. First among them is the technology’s ability to adapt to the way human beings think and act. Users want actionable intelligence, not endless queries. IMA tools, therefore, ought to interact with the investigator in a consultative way that a fellow investigator would. “Hey, have you thought about this, Mr. Investigator?” and “Maybe you should look at that.”

Second, IMA ought to have context. Technologies that simply point to two entities and say, ‘Hey these things look linked‘ are great but leave all of the thinking up to Mr. Investigator. The IMA tools that I like have contextual values associated to those links. ‘Hey, these things look linked AND here’s why that’s important’. Big difference.

Third, IMA should bring the investigations to closure. There are a lot of data mining tools out there that allow querying with case management. How, though, does the investigator get to the point where an investigation is solved and prosecutable? Once again, the most functional IMA products act the way humans do. They package up the results of the investigation in an easy-to-comprehend document that can be shared internally or with police. No loose ends.

“Every investigation ends with an investigator.”

Predictive analytics, big data, and real-time alert scoring are the current industry buzzwords. They should be. They’re important. At the end of the day, however, every investigation ends with an investigator. Putting the right tools in their hands is often the difference between success and failure in an entire enterprise investigation system.

That’s precisely what Crime Tech Solutions, LLC does. Please take a moment to look us over.

Part Two of this series is now available HERE.