Don’t Do the Crime if You Can’t Do the Time

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We’ve all heard the expression: ”don’t do the crime if you can’t do the time.” It basically means we should all think twice about breaking a rule or law if we don’t think we can handle the consequences that come along with getting caught. In today’s Fraud of the Day based on a KRISTV.com article, we learn about a case in which the ”time” was the crime and the victims were the American taxpayers in the case of a conspiracy to defraud the Medicaid program.

The article reports two women falsified timesheets using the names of former and current employees of a home health care business and submitted 628 claims to Medicaid totaling $345,393. Unbeknownst to the former and current company employees – and the company itself – the defendants then forged the names on the payroll checks created by the bogus timesheets. (Sounds like a pretty simple plan.) How much did they get for their efforts? Two managed care firms paid the defendants $155,127 of the total amount they claimed, and they split the cash. (Yeah, but was it a 50/50 split? And, if so, you still have to watch your ”partner in crime” like a hawk. That’s the downside of working with a fraudster: you can’t trust ’em from stealing your cut.)

Both defendants pleaded guilty to forging the signatures on the payroll checks. The judge ordered them to pay full restitution for the $155,127. One defendant will serve 41 months in prison, while the other will serve 51 months. (Full restitution and prison time – now, that’s what I’m talking about!)

Here’s the thing: these fraudsters received 45 percent of the total amount of false claims they submitted. And, while I’ll happily cheer the judge on for including full restitution in the sentence, I’m wondering how much ”pay” the government will get out of its ”chase” in the end. While these fraudsters may have nothing but time on their hands our civil servants have better ways to spend their time than playing a game of ”pay and chase.” It is time to use big data and analytics to examine claims before they are paid and another fraudster gets away with a crime.

Source: Today’s ”Fraud of the Day” is based on an article titled, ”Local Women Sentenced for Medicaid Fraud Scheme,” published by KRISTV.com on December 18, 2013.

CORPUS CHRISTI – Two Nueces County women who plead guilty in a conspiracy to defraud Medicaid by submitting false time sheets will spend more than three years in federal prison.

52-year-old Sylvia Salinas Ramirez of Driscoll and 42-year-old Debra Jean Velasquez of Robstown admitted they sent in the false paperwork using the names of former and current employees of of Caring Touch Home Health, also known as MRNG Inc.

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.