Tag Archives: crime analysis

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.

Part Two: Major Investigation Analytics – Big Data and Smart Data

Posted by Douglas Wood, Editor.

As regular readers of this blog know, I spend a great deal of time writing about the use of technology in the fight against crime – financial and otherwise. In Part One of this series, I overviewed the concept of Major Investigation Analytics and Investigative Case Management.

I also overviewed the major providers of this software technology – Palantir Technologies, Case Closed Software, and Visallo. The latter two recently became strategic partners, in fact.

The major case for major case management (pun intended) was driven home at a recent crime and investigation conference in New York. Full Disclosure: I attended the conference for educational purposes as part of my role at Crime Tech Weekly. Throughout the three day conference, speaker after speaker talked about making sense of data. I think if I’d have heard the term ‘big data’ one more time I’d have gone insane.  Nevertheless, that was the topic du jour as you can imagine, and the 3 V’s of big data – volume, variety, and velocity – remain a front and center topic for the vendor community serving the investigation market.

According to one report, 96% of everything we do in life – personal or at work – generates data. That statement probably best sums up how big ‘big data’ is.  Unfortunately,  there was very little discussion about how big data can help investigate major crimes. There was a lot of talk about analytics, for sure, but there was a noticeable lack of ‘meat on the bone’ when it came to major investigation analytics.

Nobody has ever yelled out “Help, I’ve been attacked. Someone call the big data!”. That’s because big data doesn’t, in and by itself, do anything.  Once you can move ‘big data’ into ‘smart data’, however, you have an opportunity to investigate and adjudicate crime. To me, smart data (in the context of investigations) is a subset of an investigator’s ability to:

  1. Quickly triage a threat (or case) using only those bits of data that are most immediately relevant
  2. Understand the larger scope of the crime through experience and crime analytics, and
  3. Manage that case through intelligence-led analytics and investigative case management, data sharing, link exploration, text analytics, and so on.

Connecting the dots, as they say. From an investigation perspective, however, connecting dots can be daunting. In the children’s game, there is a defined starting point and a set of rules.  We simply need to follow the instructions and the puzzle is solved. Not so in the world of the investigator. The ‘dots’ are not as easy to find. It can be like looking for a needle in a haystack, but the needle is actually broken into pieces and spread across ten haystacks.

Big data brings those haystacks together, but only smart data finds the needles… and therein lies the true value of major investigation analytics.