Computer Evidence Specialists

With only a name to go by, CES uncovers a large scale healthcare fraud ring

Published on 27-Mar-2013

"IBM i2 solutions helped us uncover connections and links between seemingly unrelated entities and clearly visualize those connections so we can equip the law enforcement community with the intelligence and evidence they need to disrupt fraud" - Carl Florez, President, CES

Customer:
Computer Evidence Specialists

Industry:
Professional Services

Deployment country:
United States

Overview

Computer Evidence Specialists (CES) is a professional firm which provides investigative, intelligence and analytical services to the U.S. Government, private companies and law firms. CES’s operational expertise lies in the areas of fraud matters, cyber issues and risk concerns.

Business need:
With just a name to go on, CES was challenged with confirming the existence of a large scale pharmaceutical fraud ring. To do this, they needed a solution that would help them organize and find connections hidden in a large amount of data.

Solution:
CES pulled this data into a central database where they could more easily search for entities and visualize their results, helping them to uncover connections.

Benefits:
With the help of Analyst’s Notebook and iBase, CES identified and simplified a large healthcare and drug distribution fraud ring and provided the FBI with the additional intelligence they needed to secure an indictment.

Case Study

Computer Evidence Specialists (CES) is a professional firm which provides investigative, intelligence and analytical services to the U.S. Government, private companies and law firms. CES’s operational expertise lies in the areas of fraud matters, cyber issues and risk concerns. In early 2011, CES analysts became aware that the name “Patel” was suspected to be associated with a large scale pharmaceutical scheme occurring in Michigan and Florida. Using that minimal amount of data, an analyst at CES began a search in the National Provider Identifier (NPI) registry. The NPI is a registry for healthcare providers, pharmacists and related figures in the healthcare industry who submit claims for Medicare or Medicaid reimbursement and is the entry point for doing business in the government healthcare industry. Focusing on the Michigan area and searching by the name “Patel”, CES discovered several entries in the NPI database with the name Patel. However, in order to provide law enforcement with enough information to get an indictment, CES needed to develop a better understanding of what these entries were, who and what they were connected to, and whether any of these connections were part of a fraudulent scheme.

Discovering hidden connections
CES pulled this information into their own database where they organized the new data and ran it against their existing healthcare data. As they dug deeper, leveraging public information from county healthcare records and business entities, they discovered the name Babubhai Patel was connected to several entries and documents throughout the state. With this information now in a central location, CES continued to search using Patel’s name, adding any match to a chart they created in order to visualize Patel’s network.

Continuing to dive through the data, CES identified a critical link– a cell phone number that was attached to various Patel entries. Now they had identified a legitimate and irrefutable connection between these Patel entities and connections. After sharing this information with law enforcement investigators, they discovered that this same cell number was connected to at least nine pharmacies in the state. Initially the pharmacies appeared to be owned by various individuals. However, by uncovering the connection between Patel, the cell phone number and the pharmacies, the investigators now had intelligence that suggested there was more to these pharmacies. After further investigation, CES and the FBI determined that the alleged pharmacy owners were connected to Patel and were likely just strawmen intended to mask Patel’s ownership of the pharmacies.

Critical intelligence leads to indictment
CES equipped the FBI with critical intelligence that ultimately led to an indictment by a federal grand jury in Detroit involving 26 individuals accused of participating in a large scale health care fraud and drug distribution scheme. In exchange for receiving kickbacks from Patel, participating doctors wrote unnecessary prescriptions for patients – who were also recruited into this scheme with kickbacks, and referred those patients to one of Patel’s pharmacies. Patel’s pharmacies would submit the prescriptions to insurance agencies for reimbursement even if they didn’t actually fill the prescription, or if they did, they simply gave the pills to the “patient” who would then sell them on the streets. This scheme involved several players and many layers of transactions. Armed with the intelligence CES created, the FBI was able to identify this network and provide the grand jury with a clear and concise visual depiction which helped to enable an indictment.

Ultimately, Patel and several of his associates were found guilty on August 10, 2012 on 26 counts of an indictment charging them with healthcare fraud, conspiracy and controlled substance distribution.

For more information
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Products and services used

IBM products and services that were used in this case study.

Software:
i2 iBase, i2 Analyst's Notebook

Legal Information

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