Category Archives: Fraud Detection

Program Integrity Federalism

From time to time someone among our newer Chapter members working in the insurance industry reports confronting instances of Medicaid and Medicare fraud for the first time. I thought it might be helpful to present some of the more common health care fraud scenarios that beginning fraud examiners are likely to confront in actual practice in the governmental health care space.

Abuses of the Medicaid and Medicare programs exist in myriad shapes and sizes and continue to evolve constantly. While Medicaid and Medicare fraud, waste and abuse appear to be the most egregious program issues, incidental and accidental waste also threaten program integrity, including outright criminal exploitation of governmental health care payments. Altogether, the overpayment of Medicaid and Medicare dollars represents the largest portion of misused government money, accounting for 59 percent of the $102.2 billion the government improperly distributed among all its agencies in 2017 (ACFE). Issues involving these exorbitantly expensive improper payments can be attributed, in part, to the complexities of the programs themselves and to ever-changing policies among the various states.

It’s important for new anti-fraud practitioners to be aware that while Medicaid and Medicare are considered universal programs, each state is able to operate its own version of the programs autonomously and independent of any collective standard. This autonomy creates wide-ranging policy inconsistencies due to the differences among states, and, in many ways, embodies the ideals of American federalism. How states administer programs like Medicaid and Medicare is largely influenced by the bureaucratic style employed by the state legislature. These variations and inconsistencies can facilitate inaccuracies and misunderstandings in every aspect of both programs, from recipient eligibility, billing protocols, coding standards and licensure requirements. Doctors offering Medicaid or Medicare services are not easily able to transfer their practices from one state to another without first exploring expectations and requirements of the new state. These hard state boundaries create the potential for provider, beneficiary and administrative confusion, which ultimately equates to billions of program dollars misappropriated each year.

Beyond the innocent misappropriation of program dollars are the much more serious problems with the Medicaid and Medicare programs manifesting in the form of illicit and purposeful instances of fraud, waste and abuse perpetrated by recipients and providers. Medicaid and Medicare identity theft (instances of which have been recently investigated by one of our Chapter members) much like general identify theft, has continually resurfaced as a bane since the programs’ inception. It is estimated that three percent of $50 billion of the nation’s annual identity theft losses is associated with some type of medical identity theft. Because of their likelihood of being enrolled in government-facilitated insurance programs like Medicare or Medicaid, individuals aged 50 or older are most likely to fall victim to this type of identity theft. Fraudsters steal these identities to access services, such as prescriptions for drugs with high black-market value i.e. OxyContin, Fentanyl and Morphine, intended for legally enrolled, authorized recipients. Once the prescription is obtained, the thieves sell the drugs for cash or abuse them themselves.

A similar identity theft scheme involves the sale of durable medical equipment prescribed to recipients. By stealing a beneficiary’s Medicaid or Medicare number, the perpetrator can place orders for equipment i.e. slings or braces, all paid for through program dollars, and re-sell the goods online or via newspaper classifieds for cash.

Physicians participating in the Medicaid and Medicare programs also have access to a wide range of possible fraud, waste and abuse schemes. Double billing is a common provider fraud scheme that involves the submission of duplicate claims to Medicaid or Medicare in an attempt to receive double the amount of payment for services that were only provided once. Those physicians wise to the high detectability of billing duplicate claims to either program via simple data analysis will also often send one bill to a private insurance company and a duplicate bill to Medicaid or Medicare so that the duplication does not appear within one data set. Other fraud schemes include up-coding bills to Medicare or Medicaid to represent more complex, lengthy or in-depth procedures when a simpler or lower-level service was actually provided or performed.

Usually, complex procedures are paid at a higher dollar amount than their simpler counterparts, which leads providers to be paid more money than what they actually earned during the office visit or procedure. This fraud scheme takes advantage of small but specific variations in the current procedural terminology (CPT) coding system standardized for both Medicaid and Medicare coverage. Similar to up-coding is the fraudulent unbundling of CPT codes billed as individual entities that per regulation should be grouped together and billed under one umbrella code. Usually, the umbrella code pays a discounted rate for all the services combined. Each individual code gets paid an amount that, when totaled together, equals more than what the umbrella code pays.

Dishonest Medicaid and Medicare providers also bill for services that are not medically necessary. In this scheme, providers perform and bill for services and/or testing beyond what patient need requires. Under this scheme, hospital stays are lengthened, additional diagnostic testing is ordered, entitled hospice enrollment is invoked too early, and equipment and tools are wasted for beneficiaries who really require less care and fewer services. This fraud scheme not only wastes program dollars but also strains other areas of the general healthcare system by inducing and allowing individuals to linger, thus monopolizing unnecessary services and care that could be better applied to other more worthy beneficiaries. But please be aware, while Federal regulation does not contain a definition of medical necessity, states are granted authority to develop and apply medical necessity criteria as they see fit. Providing and billing for services beyond the required needs of the beneficiary may be intentional and/or fraudulent, but because of differing state criteria, instances where unnecessary services are provided and billed may also be simply accidental or well-intentioned.

Anti-fraud professionals of all kinds should also bear in mind that, while Medical identity theft, double billing, up-coding, unbundling and billing for services not medically necessary represent only a portion of the known problems and schemes that weaken the Medicaid and Medicare programs, there are many other types of program fraud, waste and abuse occurring on a daily basis that have yet to be discovered; in this area of practice, expect the unexpected. According to the ACFE, in the past 27 years the Federal government has recovered approximately $24 billion in settlements or judgments against individuals and organizations who committed both accidental and purposeful healthcare fraud, waste and abuse.

On a state level, another $15 billion has been recouped from criminal fines and civil settlements resulting from the prosecution of healthcare fraudsters. While the $39 billion in recovered overpayments from the last 27 years is only enough to cover a small percentage of one year’s total program costs, the amount of overpayment dollars recovered each year by the Federal and state governments is growing exponentially. On average only about $1.4 billion in overpayments was recovered during that time period. However, in 2016 alone, $3.1 billion in healthcare fraud judgments and settlements was recovered by the Federal government. As Medicaid and Medicare fraud, waste and abuse schemes and problems become more prevalent their financial toll increases. Federal and state governments are also detecting and reclaiming money back on a larger scale. This increase can be attributed to developments in policy created to prevent and identify fraud, increased investigative and program integrity funding, and technological improvements in fraud detection programs, databases and software; Certified Fraud Examiners (CFE’s) will increasingly find themselves at the forefront of the effort to strengthen health care program integrity at the Federal level and within each state.

Do We Owe It?

During one of our past May training events, our speaker, shared a fascinating, real life example from her own practice of how detailed analytic analysis could be especially helpful in addressing false billing frauds. In addition, she explained at length just how this type of fraud works.

In a false billing scheme, an employee or outside party creates false vouchers or submits false invoices to a target organizational payer. These documents cause the payer to issue payments for goods or services that are either completely fictitious or overstated in price. The perpetrator then collects the fraudulent payments/checks and converts them for personal use. Another common billing fraud involves buying personal goods or services with company money.

A false billing fraud affects the purchasing cycle, causing the company to pay for nonexistent or non-essential goods or services. Most false billing frauds involve a service, since it is easier to conceal a service that is never performed than to conceal goods never received. As our speaker’s example demonstrated, the most common billing scheme, is setting up one or more bogus vendors. There are several ways to do this. The most common is to create a fictitious vendor (often called a shell company), open a bank account in the shell company’s name, and bill the victimized company. The perpetrator then creates an invoice and sends it to his/her employer. Invoices can be professionally produced via computer and desktop publishing software, typewritten, or even prepared manually. Often, the most difficult aspect of a fraudulent billing scheme is getting the false invoice approved and paid. In many instances of billing fraud, the person perpetrating the fraud is also the person in the company who is authorized to approve invoices for payment. Another popular means of getting invoice approval is to submit invoices to an inattentive, trusting, or “rubber-stamp” manager. Furthermore, perpetrators often create false supporting documents to facilitate approvals and payments, e.g., voucher packages.

A perpetrator can also use a shell company to perpetrate a pass-through billing scheme: the perpetrator places orders for goods with his shell company, has his shell company order the goods from a legitimate supplier at market prices, and then sells those goods to his employer at inflated prices. The fraud lies in the fact that the victimized company is buying the goods it needs from an unauthorized vendor at inflated prices. The perpetrator “profits” from the inflated prices gained while acting as an unauthorized middle-man in a necessary company transaction.

Rather than utilizing shell companies to overbill, some employees generate false disbursements through invoices of non-accomplice vendors. In what is called a pay and return scheme, the perpetrator makes an error in a vendor payment to facilitate the theft. One way to do that is to overpay or double-up on payments, request a check from the vendor for the excess, and steal the check when it arrives. Another scenario is to pay the wrong vendor by placing vendor checks in the wrong envelopes, then calling the vendors to explain the mistake and requesting the return of the checks. When the checks return, they are stolen. The support documents are sent through the accounts payable system a second time; and these checks are sent to the proper vendors.

Another scheme involves purchasing personal items with company money. One popular way to do this is to make a personal purchase, then run the unauthorized invoice through the accounts payable system. If the perpetrator is not in a position to approve the purchase, s/he may have to create a false purchase order to make the transaction appear legitimate or alter an existing purchase order and have an accomplice in receiving remove the excess merchandise.
Another way to purchase personal items with company money is to have the company order merchandise, then intercept the goods when they are delivered. To avoid having the merchandise delivered to the company, the perpetrator often will have it diverted to their home or some other address, such as a spouse’s business address. A third way to purchase personal items with company money is to make personal purchases on company credit cards. No matter which of the approaches is used, the perpetrator will either keep the purchases for personal use or turn the purchase into cash (or a credit card refund) by returning the merchandise.

Our event speaker pointed out that, in some ways, it’s easier to conceal a billing fraud than other frauds, but in other ways, it’s harder. It’s easier in that the perpetrator does not have to remove cash or inventory from company premises; instead, the company mails her a check. It’s more difficult in that, when the perpetrator creates a bogus vendor or shell company, s/he has to come up with a name, mailing address (often the fraudster’s home address or a postal box), and phone number (often a home phone number); open a bank account in the shell company’s name (usually requiring him or her to file or forge articles of incorporation) or in his own name; deposit and withdraw money; and create and send vendor invoices. Any of these can lead back to the perpetrator, making it easier to find him once the fraud is detected and the shell company identified.

Depending on the scheme and organizational controls in place, the perpetrator may have to falsify or alter a purchase requisition, purchase order, receiving report, or vendor invoice, or fool or force the authorizing person to approve or forge an authorization. Perpetrators involved in a pay and return fraud usually have to intercept any checks that are returned.

Our speaker additionally presented a number of red flags usually present when a false billing fraud is taking place, including:

• An unexplained increase in services performed (services that were paid for, but never performed);
• Payments to unapproved vendors;
• Invoices approved without supporting documents;
• Falsified or altered voucher documents; for example, altering a purchase order after its approval;
• Inflated prices on purchases or orders of unnecessary goods and services;
• Payments to an entity controlled by an employee;
• Multiple payments on the same invoice or over payments on an invoice;
• Personal purchases with company credit cards or charge accounts;
• Excessive returns to vendors, or full payment not received for items returned;
• A vendor with a post office box address (many post office box addresses are legitimate, but a smart.

On May 15-16th, 2019 our Chapter will be hosting a two-day ACFE lead seminar entitled, ‘How to Testify’. Our speaker, Hugo Holland, wants to make a courtroom pro out of you! Learn how to testify effectively on direct and cross examination, basic courtroom procedures, and most important, tricks for surviving on the witness stand. Improve your techniques on how to offer testimony about damages and restitution while learning to know when to draw the line between aggressive testimony and improper advocacy. Walk away with more effective report writing skills and explore the different types of evidence and legal remedies in this 2-day, ACFE instructor-led course. To review the event content and to register to attend, click here. Hope you can join us!

Fraudsters, All Too Human

Our certified Chapter members often get questions from clients and employers related to why a fraudster who’s victimized them did what he or she did. Examiners with the most experience in the process of interviewing those later convicted of fraud comment again and again about the usefulness to their overall investigation of a basic understanding of the fraudster’s basic mind set. Such knowledge can aid the examiner in narrowing down the preliminary pool of suspects, and, most importantly, assist in gaining an admission in a subsequent admissions seeking interview. ACFE experts regard fraud (and the process of interviewing) primarily as human constructs, and especially within the content of the interview process, to be able to tie in the pressure that the individual might have been under (as they perceived it) to the interview process; to understand that individual with regard to their rationalization as they were able to affect it, significantly increases the possibility of getting the compliance and cooperation that the examiner wants from the interviewee.

During your investigation, it’s important to remember that people do things for a reason. The fraud examiner might not understand the reasons a fraudster commits his or her crime, but the motivations certainly make sense to the perpetrator. For example, a perpetrator might commit fraud because her life has spiraled out of control, although it might not be out of control under a objective, reasonable person’s definition. But in the perpetrator’s view, her life has become so problematic that fraud is the only way she can see to restore balance. And during the fraud examination, if the examiner can get the suspected perpetrator to talk about the lack of control in her life, the examiner can often use this information to compel the fraudster to admit guilt and provide valuable insight into ways that similar frauds might be prevented in the future.

As a continuation of this line of thought, the examiner should consider possible human motives when examining evidence. Motive is the power that prompts a person to act. Motive, however, should not be confused with intent, which refers to the state of mind of the accused when performing the act. Motive, unlike intent, is not an essential element of crime, and criminal law generally treats a person’s motive as irrelevant in determining guilt or innocence. Even so, motive is relevant for other purposes. It can help identify the perpetrator; it will often guide the examiner to the proper rationalization; it further incriminates the accused, and it can be helpful in ensuring successful prosecution.

The examiner should search relevant documents to determine a possible motive. For example, if a fraud examiner has evidence in the form of a paycheck written to a ghost employee, she might suspect a payroll employee who recently complained about not receiving a raise in the past two years. Although such information doesn’t mean that the payroll employee committed fraud, the possible motive can guide the examiner.

ACFE experts also agree that interviewers should seek to understand the possible motives of the various suspects they encounter during an examination. To do this, interviewers should suspend their own value system. This will better position the interviewer to persuade the suspect(s) to reveal information providing insight into what might have pressured or motivated them and how they might have rationalized their actions. In an interview situation, the examiner should not suggest reasons for the crime. Instead, the examiner should let the individual share his motivations, even if the suspect reveals her motivations in an indirect manner. So when conducting an interview with a suspect, the interviewer should begin by asking questions about the standard procedures and the actual practice of the operations at issue. This is necessary to gain an understanding of the way the relevant process is intended to work as opposed to how it actually works. Additionally, asking such basic questions early in the interview will help the interviewer observe the interviewee’s normal behavior so that the interviewer can notice any changes in the subject’s mannerisms and word choice.

Always remember that there are times when rational people behave irrationally. This is important in the interview process because it will help humanize the misconduct. As indicated above, unless the perpetrator has a mental or emotional disorder, it is acceptable to expect that the perpetrator committed the fraud for a reason. Situational fraudsters (those who rationalize their right to an illegal enrichment and perpetrate fraud when the opportunity arises) do not tend to view themselves as criminals. In contrast to deviant fraudsters, who are more proactive than situational fraudsters and who are always on the alert for opportunities to commit fraud, situational fraudsters rationalize their crimes. Situational fraudsters feel that they need to commit fraud to regain control over their lives. Thus, an interviewer will be more likely to obtain a confession from a situational fraudster if she can genuinely communicate that she understands how anyone under similar circumstances might commit such a crime. Genuineness, however, is key. If the fraudster in any way detects that the interviewer is presenting a trap, he generally will not make any admission of wrongdoing.

So, in your examinations, never lose sight of the human element; that by definition, fraud involves human deception for personal gain. Why do people deceive to get what they want, or in some cases, what they need? Most humans commit deceptive acts to protect themselves from various consequences of the truth. Avoiding punishment is the most common reason for deception, but there are other reasons, including to protect another person, to win the admiration or respect of others, to avoid embarrassment, enjoy the thrill of accomplishment and to avoid hard work to achieve goals. When people feel that their self-security is threatened, they might resort to deception to preserve their image. Further, people can become so engaged in managing how others perceive them that they become unable to separate the truth from fiction in their own minds.

The ability to sympathetically cast oneself into the human situation of others is one of the most valuable skills that a fraud examiner can have in our efforts to determine the truth.

Cash In – Cash Out

One of our associate Chapter members has become involved in her first fraud investigation just months after graduating from university and joining her first employer. She’s working for a restaurant management consulting practice and the investigation involves cash theft targeting the cash registers of one of the firm’s smaller clients. Needless to say, we had a lively discussion!

There are basically two ways a fraudster can steal cash from his or her employer. One is to trick the organization into making a payment for a fraudulent purpose. For instance, a fraudster might produce an invoice from a nonexistent company or submit a timecard claiming hours that s/he didn’t really work. Based on the false information that the fraudster provides, the organization issues a payment, e.g., by sending a check to the bogus company or by issuing an inflated paycheck to the employee. These schemes are known as fraudulent disbursements of cash. In a fraudulent disbursement scheme, the organization willingly issues a payment because it thinks that the payment is for a legitimate purpose. The key to the success of these types of schemes is to convince the organization that money is owed.

The second way (as in our member’s restaurant case) to misappropriate cash is to physically remove it from the organization through a method other than the normal disbursement process. An employee takes cash out of his cash register, puts it in his pocket, and walks out the door. Or, s/he might just remove a portion of the cash from the bank deposit on their way to the bank. This type of misappropriation is what is referred to as a cash theft scheme. These schemes reflect what most people think of when they hear the term “theft”; a person simply grabs the money and sneaks away with it.

What are commonly denoted cash theft schemes divide into two categories, skimming and larceny. The difference between whether it’s skimming or larceny depends completely on when the cash is stolen, a distinction confusing to our associate member. Cash larceny is the theft of money that has already appeared on a victim organization’s books, while skimming is the theft of cash that has not yet been recorded in the accounting system. The way an employee extracts the cash may be exactly the same for a cash larceny or skimming scheme. Because the money is stolen before it appears on the books, skimming is known as an “off-book” fraud. The absence of any recorded entry for the missing money also means there is no direct audit trail left by a skimming scheme. The fact that the funds are stolen before they are recorded means that the organization may not be “aware” that the cash was ever received. Consequently, it may be very difficult to detect that the money has been stolen.

The basic structure of a skimming scheme is simple: Employee receives payment from a customer, employee pockets payment, employee does not record the payment. There are a number of variations on the basic plot, however, depending on the position of the perpetrator, the type of company that is victimized, and the type of payment that is skimmed. In addition, variations can occur depending on whether the employee skims sales or receivables (this post is only about sales).

Most skimming, particularly in the retail sector, occurs at the cash register – the spot where revenue enters the organization. When the customer purchases merchandise, he or she pays a cashier and leaves the store with whatever s/he purchased, i.e., a shirt, a meal, etc. Instead of placing the money in the cash register, the employee simply puts it in his or her pocket without ever recording the sale. The process is made much easier when employees at cash collection points are left unsupervised as is the case in many small restaurants. A common technique is to ring a “no sale” or some other non-cash transaction on the employee’s register. The false transaction is entered on the register so that it appears that the employee is recording the sale. If a manager is nearby, it will look like the employee is following correct cash receipting procedures, when in fact the employee is stealing the customer’s payment. Another way employees sometimes skim unrecorded sales is by conducting sales during nonbusiness hours. For instance, many employees have been caught selling company merchandise on weekends or after hours without the knowledge of the owners. In one case, a manager opened his store two hours early every day and ran it business-as-usual, pocketing all sales made during the “unofficial” store hours. As the real opening time approached, he would destroy all records from the off-hours transactions and start the day from scratch.

Although sales skimming does not directly affect the books, it can show up on a company’s records in indirect ways, usually as inventory shrinkage; this is how the skimming thefts were detected at our member’s client. The bottom line is that unless skimming is being conducted on a very large scale, it is usually easier for the fraudster to ignore the shrinkage problem. From a practical standpoint, a few missing pieces of inventory are not usually going to trigger a fraud investigation. However, if a skimming scheme is large enough, it can have a marked effect on a small business’ inventory, especially in a restaurant where profit margins are always tight and a few bad sales months can put the concern out of business. Small business owners should conduct regular inventory counts and make sure that all shortages are promptly investigated and accounted for.

Any serious attempt to deter and detect cash theft must begin with observation of employees.  Skimming and cash larceny almost always involve some form of physical misappropriation of cash or checks; the perpetrator actually handles, conceals, and removes money from the company. Because the perpetrator will have to get a hold of funds and actually carry them away from the company’s premises, it is crucial for management to be able to observe employees who handle incoming cash.

Fraud Detection-Fraud Prevention

One of our CFE chapter members left us a contact comment asking whether concurrent fraud auditing might not be a good fraud prevention tool for use by a retailer client of hers that receives hundreds of credit card payments for services each day. The foundational concepts behind concurrent fraud auditing owe much to the idea of continuous assurance auditing (CAA) that internal auditors have applied for years; I personally applied the approach as an essential tool throughout by carrier as a chief audit executive (CAE). Basically, the heart of a system of concurrent fraud auditing (CFA) like that of CAA is the process of embedding control based software monitors in real time, automated financial or payment systems to alert reviewers of transactional anomalies in as close to their occurrence as possible. Today’s networked/cloud based processing environments have made the implementation and support of such real time review approaches operationally feasible in ways that the older, batch processing based environments couldn’t.

Our member’s client uses several on-line, cloud based services to process its customer payments; these services provide our member’s client with a large database full of payment history, tantamount to a data warehouse, all available for use on SQL server, by in-house client IT applications like Oracle and SAP. In such a data rich environment, CFE’s and other assurance professionals can readily test for the presence of transactional patterns characteristic of defined, common payment fraud scenarios such as those associated with identity theft and money laundering. The objective of the CFA program is not necessarily to recover the dollars associated with on-line frauds but to continuously (in as close to real time as possible) adjust the edits in the payment collection and processing system so that certain fraudulent transactions (those associated with known fraud scenarios) stand a greater chance of not even getting processed in the first place. Over time, the CFA process should get better and better at editing out or flagging the anomalies associated with your defined scenarios.

The central concept of any CFA system is that of an independent application monitoring for suspected fraud related activity through, for example (as with our Chapter member), periodic (or even real time) reviews of the cloud based files of an automated payment system. Depending upon the degree of criticality of the results of its observations, activity summaries of unusual items can be generated with any specified frequency and/or highlighted to an exception report folder and communicated to auditors via “red flag” e-mail notices. At the heart of the system lies a set of measurable, operational metrics or tags associated with defined fraud scenarios. The fraud prevention team would establish the metrics it wishes to monitor as well as supporting standards for those metrics. As a simple example, the U.S. has established anti-money-laundering banking rules specifying that all transactions over $10,000 must be reported to regulators. By experience, the $10,000 threshold is a fraud related metric investigators have found to be generic in the identification of many money-laundering fraud scenarios. Anti-fraud metric tags could be built into the cloud based financial system of our Chapter member’s client to monitor in real time all accounts payable and other cash transfer transactions with a rule that any over $10,000 would be flagged and reviewed by a member of the audit staff. This same process could have multiple levels of metrics and standards with exceptions fed up to a first level assurance process that could monitor the outliers and, in some instances, send back a correcting feedback transaction to the financial system itself (an adjusting or corrective edit or transaction flag). The warning notes that our e-mail systems send us that our mailboxes are full are another example of this type of real time flagging and editing.

Yet other types of discrepancies would flow up to a second level fraud monitoring or audit process. This level would produce pre-formatted reports to management or constitute emergency exception notices. Beyond just reports, this level could produce more significant anti-fraud or assurance actions like the referral of a transaction or group of transactions to an enterprise fraud management committee for consideration as documentation of the need for an actual future financial system fraud prevention edit. To continue the e-mail example, this is where the system would initiate a transaction to prevent future mailbox accesses to an offending e-mail user.

There is additionally yet a third level for our system which is to use the CFA to monitor the concurrent fraud auditing process itself. Control procedures can be built to report monitoring results to external auditors, governmental regulators, the audit committee and to corporate council as documented evidence of management’s performance of due diligence in its fight against fraud.

So I would encourage our member CFE to discuss the CFA approach with the management of her client. It isn’t the right tool for everyone since such systems can vary greatly in cost depending upon the existing processing environment and level of IT sophistication of the implementing organization. CFA’s are particularly useful for monitoring purchase and payment cycle applications with an emphasis on controls over customer and vendor related fraud. CFA is an especially useful tool for any financial application where large amounts of cash are either coming in or going out the door (think banking applications) and to control all aspects of the processing of insurance claims.

Detect and Prevent

I got a call last week from a long term colleague, one of whose smaller client firms recently discovered a long running key-employee initiated fraud. My friend has been asked to assist her client in developing approaches to strengthen controls to, hopefully, prevent such disasters in the future.

ACFE training has consistently told us over the years, and daily experience repeatedly confirmed, that it is simply not possible or economical to stop all fraud before it happens. The only way for a retail concern to absolutely stop shoplifting might be to close and accept orders only over the Internet. Similarly, the only way for a bank to absolutely stop all loan fraud might be for it to stop lending money.

In general, my friend and I agreed during our conversation, that increasing preventive security can reduce fraud losses, but beyond some point, the cost of additional preventive security will exceed the related savings from reduced fraud losses. This is where detection comes in; it may be economical when prevention is not. One way to prevent a salesclerk from stealing from the register would be for the security department to carefully monitor, review, and approve every one of the clerk’s sales. However, it would likely be much more cost effective instead to implement a simple detective control: an end-of-shift reconciliation between the cash in the register and the transactions logged by the cash register during the clerk’s shift. If refunds are not given at the point of sale, the end-of-shift balance of cash in the register should equal the shift’s sales per the transaction logs minus the balance of cash in the register at the beginning of the shift. Any significant failure of these numbers to reconcile would amount to a red flag. Of course, further investigation could show that the clerk simply made an error and so did not commit fraud.

But the cost effectiveness of detective controls, like preventive controls, imposes limits. First, such controls are not cost free to implement, and improving detective controls may cost more than the results they provide. Second, detective controls produce both false positives and false negatives. A false positive occurs when a detective control signals a possible fraud that upon investigation turns up a reasonable explanation for the indicator. A false negative occurs when a detective control fails to signal a possible fraud when one exists. Reducing false negatives means increasing the fraud detection rate.

Similarly, the cost effectiveness of increasing preventive security has a limit as does the benefit of increasing the fraud detection rate. To increase the detection rate, it’s necessary to increase the frequency at which the detective control signals possible fraud. The result is more expensive investigations, and the cost of such additional investigations can exceed the resulting reduction in fraud losses.

As we all learned in undergraduate auditing, controls are essentially policies and procedures designed to minimize losses due to fraud or to other events such as errors or acts of nature. Corrective controls are merely special control types involved once a loss is known to exist. With respect to fraud, an important corrective control involves the investigation of potential frauds and the investigation and recovery process from discovered frauds.

More generally speaking, fraud investigations themselves serve not only a corrective function but also detective and preventive functions. Such investigations are detective of fraud to the extent that they follow up on fraud signals or red flags in order to confirm or disconfirm the presence of fraud. But once fraud is confirmed to exist, fraud examinations shift toward gathering evidence and become corrective by assisting in recovery from the perpetrator and other sources such as from insurance. Fraud investigations are also corrective in that they can lead to the revelation and repair of heretofore unknown weaknesses.

The end result is that the fraud investigation functions to correct the original loss, and the related discovery of the fraud scenario leads to prevention of similar losses in the future. In summary, the fraud examination has served to detect, correct, and prevent fraud. However, fraud investigations are not normally thought of as detective controls. This so is because fraud investigations tend to be much more costly than standard detective controls and therefore are normally used only when there is already some predication in the form of a fraud indicator triggered by a typical detective control. Therefore, the primary functions of fraud investigations are to address existing frauds and help to prevent future ones.

In some cases, the primary benefit of a fraud investigation might be to prevent future frauds. Even when recovery is impossible or impractical (e.g., because the thief has no assets), unwinding the fraud scheme may still have the benefit of leading to the prevention of the same scheme in the future. Furthermore, a company might benefit from spending a very large sum of money to investigate and prosecute a very small theft in order to deter other individuals from defrauding the company in the same way. Many State governments have statutes specifying that every fraud affecting governmental assets, whether large or small, must be fully investigated because taxpayer funds are involved (the assets affected are public property).

There is never a guarantee that investigating a fraud indicator will lead to the discovery of fraud. Depending on the situation, an investigation might lead to nothing at all (i.e., produce a reasonable explanation for the original red flag) or to the discovery of losses due to simple errors, waste, inefficiencies, or even uncontrollable events like acts of nature. If a lender is considering a loan application, a fraud indicator might indicate nothing, fraud, or an error. On the other hand, in regard to the possible theft of raw materials in a production process, a fraud indicator just might indicate undocumented waste or scrap.

Two important factors to consider concerning the general design of a fraud detection process are not only the costs and benefits of detecting, correcting, and preventing a given fraud scenario but also the costs and benefits of detecting, correcting, and preventing errors, waste, uncontrollable events, and inefficiencies in general. Of course, the particular costs that are relevant will vary from one type of business process to another.

As a general rule, we can say that both preventive controls and detective controls cost less than corrective controls. Corrective controls tend to involve hands-on, resource-intensive investigations, and in many cases, such investigations do not result in recovering the loss. On the other hand, preventive controls can also be quite costly. Banks pay armed guards and incur costs to maintain expensive vaults and alarm systems. Companies surround their headquarters with high fences and armed guards, and use security checkpoints and biometric key card systems inside. On the information technology side, firms use sophisticated firewalls and multi-layer access controls. The costs of all these preventive measures can add up to staggering sums in large companies. Of course, losses that are not prevented or corrected in a timely fashion can lead to the ultimate corrective measure: bankruptcy. In fact, some ACFE estimates show that about one-third of all business failures relate to some form of fraudulent activity.

One positive aspect of the cost of preventive controls is that unlike detective controls, they do not generate fraud indicators that lead to costly investigations. In fact, they tend to do their job in complete silence so that management never even knows when they prevent a fraud. The thick door of a bank vault with a time lock prevents bank employees from entering the building at night to steal its contents. Similarly, passwords, pin numbers, and biometric data silently provide access to authorized individuals and prevent access from others.

The problem with preventive controls is that they are always subject to circumvention by determined and cunning fraudsters. There is no perfect solution to preventing acts of fraud, so detection is necessary as a secondary line of defense, and in some cases, as the primary line of defense. Consider a lending company that accepts online loan applications. It may be difficult or impossible to prevent fraudulent applications, but the company can certainly put a sophisticated (and expensive) system in place to analyze applications and provide indicators that suggest when an application may be fraudulent.

In general, the optimal allocation of resources to prevention versus detection depends on the particular business process under consideration. So, there is no general rule that dictates the optimal allocation of resources between prevention versus detection. But there are some general steps that can assist in making the allocation:

1. Analyze the target business process and identify threats and vulnerabilities.
2. Select reasonable preventive controls according to the business process and customs within the client’s industry.
3. Estimate fraud losses given the assumed preventive controls.
4. Identify and add a basic set of detective controls to the system.
5. For a given set of detective controls, identify the optimal mix of false negatives versus false positives. The optimal mix depends on the costs of investigations versus the costs of losses. Large losses and small investigation costs favor relatively low false negatives and high false positives for red flags.
6. Given the assumed mix of false negative and false positive errors, estimate the incremental cost associated with adding the detective (and related corrective) controls, and estimate the resulting reduction in fraud losses.
7. Compare the reduction in fraud losses with the increase in costs associated with adding the optimal mix of detection and correction controls.
8. If increase in costs is significantly lower than the related reduction in fraud losses, consider adding more detective controls. Otherwise, accept the set of detective controls under consideration.

The Unsanctioned Invoice

Of all the frauds classified as occupational, one of the most pernicious encountered by CFEs is the personal purchase with company funds scam. I say pernicious because not only is this type of fraud a cancer, devouring it’s host organization from within, but also because this basic fraud scenario can take on so many different forms.

Instead of undertaking externally involved schemes to generate cash, many employed fraudsters choose to betray their employers by simply purchasing personal items with their company’s money. Company accounts are used by the vampires to buy items for their side businesses and for their families. The list of benefiting recipients goes on and on. In one case a supervisor started a company for his son and directed work to the son’s company. In addition to this ethically challenged behavior, the supervisor saw to it that his employer purchased all the materials and supplies necessary for running the son’s business. As the fraud matured, the supervisor purchased materials through his employer that were used to add a room to his own house. All in all, the perpetrator bought nearly $50,000 worth of supplies and materials for himself and various others using company money.

One might wonder why a purchases fraud is not classified by the ACFE as a theft of inventory or other assets rather than as a billing scheme. After all, in purchases schemes the fraudster buys something with company money, then takes the purchased item for himself or others. In the case cited above, the supervisor took building materials and supplies. How does this differ from those frauds where employees steal supplies and other materials? On first glance, the schemes appear very similar. In fact, the perpetrator of a purchases fraud is stealing inventory just as s/he would in any other-inventory theft scheme. Nevertheless, the heart of the scheme is not the taking of the inventory but the purchasing of the inventory. In other words, when an employee steals merchandise from a warehouse, s/he is stealing an asset that the company needs, an asset that it has on hand for a particular reason. The harm to the victim company is not only the cost of the asset, but the loss of the asset itself. In a purchasing scheme, on the other hand, the asset which is taken is superfluous. The perpetrator causes the victim company to order and pay for an asset which it does not really need in the course of business, so the only damage to the victim company is the money lost in purchasing the particular item. This is why purchasing schemes are categorized as invoice frauds.

Most of the employees identified by the ACFE as undertaking purchase schemes do so by running unsanctioned invoices through the accounts payable system. The fraudster buys an item and submits the bill to his employer as if it represented a purchase on behalf of the company. The goal is to have the company pay the invoice. Obviously, the invoice which the employee submits to his company is not legitimate. The main hurdle for a fraudster to overcome, therefore, is to avoid scrutiny of the invalid invoice and to obtain authorization for the bill to be paid.

As in the many cases of shell company related schemes we’ve written about on this blog, the person who engages in a purchases scheme is often the very person in the company whose duties include authorizing purchases. Obviously, proper controls should preclude anyone from approving her own purchases. Such poorly separated functions leave little other than her conscience to dissuade an employee from fraud. Nevertheless, CFEs see many examples of small to medium sized companies in which this lapse in controls exists. As the ACFE continues to point out, fraud arises in part because of a perceived opportunity. An employee who sees that no one is reviewing his or her actions is more likely to turn to fraud than one who knows that her company applies due diligence in the attempt to detect all employee theft.

An example of how poor controls can lead to fraud was the case where a manager of a remote location of a large, publicly traded company was authorized to both order supplies and approve vendor invoices for payment. For over a year, the manager routinely added personal items and supplies for his own business to orders made on behalf of his employer. The orders often included a strange mix of items; technical supplies and home furnishings might, for instance, be purchased in the same order. Because the manager was in a position to approve his own purchases, he could get away with such blatantly obvious frauds. In addition to ordering personal items, the perpetrator changed the delivery address for certain supplies so that they would be delivered directly to his home or side business. This scheme cost the victim company approximately $300,000 in unnecessary purchases. In a similar case, an employee with complete control of purchasing and storing supplies for his department bought approximately $100,000 worth of unnecessary supplies using company funds. The employee authorized both the orders and the payments. The excess supplies were taken to the perpetrator’s home where he used them to manufacture a product for his own business. It should be obvious that not only do poor controls pave the way for fraud, a lack of oversight regarding the purchasing function can allow an employee to remove huge amounts from the company’s bottom line.

Not all fraudsters are free to approve their own purchases. Those who cannot must rely on other methods to get their personal bills paid by the company. The chief control document in many voucher systems is the purchase order. When an employee wants to buy goods or services, s/he submits a purchase requisition to a superior. If the purchase requisition is approved, a purchase order is sent to a vendor. A copy of this purchase order, retained in the voucher, tells accounts payable that the transaction has been approved. Later, when an invoice and receiving report corresponding to this purchase order are assembled, accounts payable will issue a check.

So in order to make their purchases appear authentic, some fraudsters generate false purchase orders. In one case, an employee forged the signature of a division controller on purchase orders. Thus the purchase orders appeared to be authentic and the employee was able to buy approximately $3,000 worth of goods at his company’s expense. In another instance, a part time employee at an educational institution obtained unused purchase order numbers and used them to order computer equipment under a fictitious name. The employee then intercepted the equipment as it arrived at the school and loaded the items into his car. Eventually, the employee began using fictitious purchase order numbers instead of real ones. The scheme came to light when the perpetrator inadvertently selected the name of a real vendor. After scrutinizing the documents, the school knew that it had been victimized. In the meantime, the employee had bought nearly $8,000 worth of unnecessary equipment.

Purchase orders can also be altered by employees who seek to obtain merchandise at their employer’s expense. In one instance, several individuals conspired to purchase over $2 million worth of materials for their personal use. The ringleader of the scheme was a low-level supervisor who had access to the computer system which controlled the requisition and receipt of materials. This supervisor entered the system and either initiated orders of materials that exceeded the needs of a particular project or altered existing orders to increase the amount of materials being requisitioned. Because the victim organization had poor controls, it did not compare completed work orders on projects to the amount of materials ordered for those projects. This allowed the inflated orders to go undetected.

Another way for an employee to get a false purchase approved is to misrepresent the nature of the purchase. In many companies, those with the power to authorize purchases are not always attentive to their duties. If a trusted subordinate vouches for an acquisition, for instance, busy supervisors often give rubber stamp approval to purchase requisitions. Additionally, employees sometimes misrepresent the nature of the items they are purchasing in order to pass a cursory review by their superiors.

Instead of running false invoices through accounts payable, some employees make personal purchases on company credit cards or running accounts with vendors. As with invoicing schemes, the key to getting away with a false credit card purchase is avoiding detection. Unlike invoicing schemes, however, prior approval for purchases is not required. An employee with a company credit card can buy an item merely by signing his or her name (or forging someone else’s) at the time of purchase. Later review of the credit card statement, however, may detect the fraudulent purchase.

As with invoicing schemes, those who committed the frauds were often in a position to approve their own purchases;, the same is often true with credit card schemes. A manager in one case, reviewed and approved his own credit card statements. This allowed him to make fraudulent purchases on the company card for approximately two years.

Finally, there is, the fraudster who buys items and then returns them for cash. A good example of such a scheme is that in which an employee made fraudulent gains from a business travel account. The employee’s scheme began by purchasing tickets for herself and her family through her company’s travel budget. Poor separation of duties allowed the fraudster to order the tickets, receive them, prepare claims for payments, and distribute checks. The only review of her activities was made by a busy and rather uninterested supervisor who approved the employee’s claims without requiring support documentation. Eventually, the employee’s scheme evolved. She began to purchase airline tickets and return them for their cash value. An employee of the travel agency assisted in the scheme by encoding the tickets as though the fraudster had paid for them herself. That caused the airlines to pay refunds directly to the fraudster rather than to her employer. In the course of two years, this employee embezzled over $100,000 through her purchases scheme.

Concealment Strategies & Fraud Scenarios

I remember Joseph Wells mentioning at an ACFE conference years ago that identifying the specific asset concealment strategy selected by a fraudster was often key to the investigator’s subsequent understanding of the entire fraud scenario the fraudster had chosen to implement. What Joe meant was that a fraud scenario is the unique way the inherent fraud scheme has occurred (or can occur) at an examined entity; therefore, a fraud scenario describes how an inherent fraud risk will occur under specific circumstances. Upon identification, a specific fraud scenario, and its associated concealment strategy, become the basis for fraud risk assessment and for the examiner’s subsequent fraud examination program.

Fraud concealment involves the strategies used by the perpetrator of the fraud scenario to conceal the true intent of his or her transaction(s). Common concealment strategies include false documents, false representations, false approvals, avoiding or circumventing control levels, internal control evasion, blocking access to information, enhancing the effects of geographic distance between documents and controls, and the application of both real and perceived pressure. Wells also pointed out that an important aspect of fraud concealment pertains to the level of sophistication demonstrated by the perpetrator; the connection between concealment strategies and fraud scenarios is essential in any discussion of fraud risk structure.

As an example, consider a rights of return fraud scenario related to ordered merchandise. Most industries allow customers to return products for any number of reasons. Rights of return refers to circumstances, whether as a matter of contract or of existing practice, under which a product may be returned after its sale either in exchange for a cash refund, or for a credit applied to amounts owed or to be owed for other products, or in exchange for other products. GAAP allows companies to recognize revenue in certain cases, even though the customer may have a right of return. When customers are given a right of return, revenue may be recognized at the time of sale if the sales price is substantially fixed or determinable at the date of sale, the buyer has paid or is obligated to pay the seller, the obligation to pay is not contingent on resale of the product, the buyer’s obligation to the seller does not change in the event of theft or physical destruction or damage of the product, the buyer acquiring the product for resale is economically separate from the seller, the seller does not have significant obligations for future performance or to bring about resale of the product by the buyer, and the amount of future returns can be reasonably estimated.

Sales revenue not recognizable at the time of sale is recognized either once the return privilege has substantially expired or if the conditions have been subsequently met. Companies sometimes stray by establishing accounting policies or sales agreements that grant customers vague or liberal rights of returns, refunds, or exchanges; that fail to fix the sales price; or that make payment contingent upon resale of the product, receipt of funding from a lender, or some other future event. Payment terms that extend over a substantial portion of the period in which the customer is expected to use or market the purchased products may also create problems. These terms effectively create consignment arrangements, because, no economic risk has been transferred to the purchaser.

Frauds in connection with rights of return typically involve concealment of the existence of the right, either by contract or arising from accepted practice, and/or departure from GAAP specified conditions. Concealment usually takes one or more of the following forms:

• Use of side letters: created and maintained separate and apart from the sales contract, that provide the buyer with a right of return;

• Obligations by oral promise or some other form of understanding between seller and buyer that is honored as a customary practice but arranged covertly and hidden;

• Misrepresentations designed to mischaracterize the nature of arrangements, particularly in respect of:

–Consignment arrangements made to appear to be final sales;

–Concealment of contingencies, under which the buyer can return the products, including failure to resell the products, trial periods, and product performance conditions;

–Failure to disclose the existence, or extent, of stock rotation rights, price protection concessions, or annual returned-goods limitations;

–Arrangement of transactions, with straw counterparties, agents, related parties, or other special purpose entities in which the true nature of the arrangements is concealed or obscured, but, ultimately, the counterparty does not actually have any significant economic risk in the “sale”.

Sometimes the purchaser is complicit in the act of concealment, for example, by negotiating a side letter, and this makes detection of the fraud even more difficult. Further, such frauds often involve collusion among several individuals within an organization, such as salespersons, their supervisors, and possibly both marketing and financial managers.

It’s easy to see that once a CFE has identified one or more of these concealment strategies as operative in a given entity, the process of developing a descriptive fraud scenario, completing a related risk assessment and constructing a fraud examination program will be a relatively straight forward process. As a working example, of a senario and related concealment strategies …

Over two decades ago the SEC charged a major computer equipment manufacturer with overstating revenue in the amount of $500,000 on transactions for which products had been shipped, but for which, at the time of shipment, the company had no reasonable expectation that the customer would accept and pay for the products. The company eventually accepted back most of the product as sales returns during the following quarter.

The SEC noted that the manufacturer’s written distribution agreements generally allowed the distributor wide latitude to return product to the company for credit whenever the product was, in the distributor’s opinion, damaged, obsolete, or otherwise unable to be sold. According to the SEC, in preparing the manufacturer’s financial statements for the target year, company personnel submitted a proposed allowance for future product returns that was unreasonably low in light of the high level of returns the manufacturer had received in the first several months of the year.

The SEC determined that various officers and employees in the accounting and sales departments knew the exact amount of returns the company had received before the year end, when the company’s independent auditors finished their fieldwork on the annual audit. Had the manufacturer revised the allowance for sales returns to reflect the returns information, the SEC concluded it would have had to reduce the net revenue reported for the fiscal year. Instead, the SEC found that several of the manufacturer’s officers and employees devised schemes to prevent the auditors from discovering the true amount of the returns, including 1), keeping the auditors away from the area at the manufacturer’s headquarters where the returned goods were stored, and 2), accounting personnel altering records in the computer system to reduce the level of returns. After all the facts were assembled, the SEC took disciplinary action against several company executives.

As with side agreements, a broad base of inquiry into company practices may be one of the best assessment techniques the CFE has regarding possible concealment strategies supporting fraud scenarios involving returns and exchanges. In addition to inquiries of this kind, the ACFE recommends that CFE’s may consider using analytics like:

• Compare returns in the current period with prior periods and ask about unusual increases.

• Because companies may slow the return process to avoid reducing sales in the current period, determine whether returns are processed in timely fashion. The facts can also be double-checked by confirming with customers.

• Calculate the sales return percentage (sales returns divided by total sales) and ask about any unusual increase.

• Compare returns after a reporting period with both the return reserve and the monthly returns to determine if they appear reasonable.

• Determine whether sales commissions are paid at the time of sale or at the time of collection. Sales commissions paid at the time of sale provide incentives to inflate sales artificially to meet internal and external market pressures.

• Determine whether product returns are adjusted from sales commissions. Sales returns processed through the so-called house account may provide a hidden mechanism to inflate sales to phony customers, collect undue commissions, and return the product to the vendor without being penalized by having commissions adjusted for the returned goods.

Finding the Words

I had lunch with a long-time colleague the other day and the topic of conversation having turned to our May training event next week, he commented that when conducting a fraud examination, he had always found it helpful to come up with a list of words specifically associated with the type of fraud scenario on which he was working.  He found the exercise useful when scanning through the piles of textual material he frequently had to plow through during complex examinations.

Data analysis in the traditional sense involves running rule-based queries on structured data, such as that contained in transactional databases or financial accounting systems. This type of analysis can yield valuable insight into potential frauds. But, a more complete analysis requires that fraud examiners (like my friend) also consider unstructured textual data. Data are either structured or unstructured. Structured data is the type of data found in a database, consisting of recognizable and predictable structures. Examples of structured data include sales records, payment or expense details, and financial reports. Unstructured data, by contrast, is data that would not be found in a traditional spreadsheet or database. It is typically text based.

Our client’s employees are sending and receiving more email messages each year, retaining ever more electronic source documents, and using more social media tools. Today, we can anticipate unstructured data to come from numerous sources, including:

• Social media posts
• Instant messages
• Videos
• Voice files
• User documents
• Mobile phone software applications
• News feeds
• Sales and marketing material
• Presentations

Textual analytics is a method of using software to extract usable information from unstructured text data. Through the application of linguistic technologies and statistical techniques, including weighted fraud indicators (e.g., my friend’s fraud keywords) and scoring algorithms, textual analytics software can categorize data to reveal patterns, sentiments, and relationships indicative of fraud. For example, an analysis of email communications might help a fraud examiner gauge the pressures/incentives, opportunities, and rationalizations to commit fraud that exist in a client organization.

According to my colleague, as a prelude to textual analytics (depending on the type of fraud risk present in a fraud examiner’s investigation), the examiner  will frequently profit by coming up with a list of fraud keywords that are likely to point to suspicious activity. This list will depend on the industry of the client, suspected fraud schemes, and the data set the fraud examiner has available. In other words, if s/he is running a search through journal entry detail, s/he will likely search for different fraud keywords than if s/he were running a search of emails. It might be helpful to look at the ACFE’s fraud triangle when coming up with a keyword list. The factors identified in the triangle are helpful when coming up with a fraud keyword list. Consider how someone in the entity under investigation might have the opportunity to commit fraud, be under pressure to commit fraud, or be able to rationalize the commission of fraud.

Many people commit fraud because of something that has happened in their life that motivates them to steal. Maybe they find themselves in debt, or perhaps they must meet a certain goal to qualify for a performance-based bonus. Keywords that might indicate pressure include deadline, quota, trouble, short, problem, and concern. Think of words that would indicate that someone has the opportunity or ability to commit fraud. Examples include override, write-off, recognize revenue, adjust, discount, and reserve/provision.

Since most fraudsters do not have a criminal background, justifying their actions is a key part of committing fraud. Some keywords that might indicate a fraudster is rationalizing his actions include reasonable, deserve, and temporary.

So, even though the concepts embodied in the fraud triangle are a good place to start when developing a keyword list, it’s also important to consider the nature of the client entity’s industry and the types of payments it makes or is suspected of making. Think about the fraud scenarios that are likely to have occurred. Does the entity do a significant amount of work overseas or have many contractors? If so, there might be an elevated risk of bribery. Focus on the payment text descriptions in journal entries or in work delated documentation, since no one calls it “bribe expense.” Some examples of word combinations in payment descriptions that might merit special attention include:

• Goodwill payment
• Consulting fee
• Processing fee
• Incentive payment
• Donation
• Special commission
• One-time payment
• Special payment
• Friend fee
• Volume contract incentive

Any payment descriptions bearing these, or similar terms warrant extra scrutiny to check for reasonableness. Also, examiners should always be wary of large cash disbursements that have a blank journal payment description.

Beyond key word lists, the ACFE tells us that another way to discover fraud clues hidden in text is to consider the emotional tone of employee correspondence. In emails and instant messages, for instance, a fraud examiner should identify derogatory, surprised, secretive, or worried communications. In one example, former Enron CEO Ken Lay’s emails were analyzed, revealing that as the company came closer to filing bankruptcy, his email correspondence grew increasingly derogatory, confused, and angry. This type of analysis provided powerful evidence that he knew something was wrong at the company.

While advanced textual analytics can be extremely revealing and can provide clues for potential frauds that might otherwise go unnoticed, the successful application of such analytics requires the use of sophisticated software, as well as a thorough understanding of the legal environment of employee rights and workplace searches. Consequently, fraud examiners who are considering adding textual analytics to their fraud detection arsenal should consult with technological and legal experts before undertaking such techniques.

Even with sophisticated data analysis techniques, some data are so vast or complex that they remain difficult to analyze using traditional means. Visually representing data via graphs,  link diagrams, time-series charts, and other illustrative representations can bring clarity to a fraud examination. The utility of visual representations is enhanced as data grow in volume and complexity. Visual analytics build on humans’ natural ability to absorb a greater volume of information in visual rather than numeric form and to perceive certain patterns, shapes, and shades more easily than others.

Link analysis software is used by fraud examiners to create visual representations (e.g., charts with lines showing connections) of data from multiple data sources to track the movement of money; demonstrate complex networks; and discover communications, patterns, trends, and relationships. Link analysis is very effective for identifying indirect relationships and relationships with several degrees of separation. For this reason, link analysis is particularly useful when conducting a money laundering investigation because it can track the placement, layering, and integration of money as it moves around unexpected sources. It could also be used to detect a fictitious vendor (shell company) scheme. For instance, the investigator could map visual connections between a variety of entities that share an address and bank account number to reveal a fictitious vendor created to embezzle funds from a company.  The following are some other examples of the analyses and actions fraud examiners can perform using link analysis software:

• Associate communications, such as email, instant messages, and internal phone records, with events and individuals to reveal connections.
• Uncover indirect relationships, including those that are connected through several intermediaries.
• Show connections between entities that share an address, bank account number, government identification number (e.g., Social Security number), or other characteristics.
• Demonstrate complex networks (including social networks).

Imagine a listing of vendors, customers, employees, or financial transactions of a global company. Most of the time, these records will contain a reference to a location, including country, state, city, and possibly specific street address. By visually analyzing the site or frequency of events in different geographical areas, a fraud investigator has yet another variable with which s/he can make inferences.

Finally, timeline analysis software aids fraud examiners in transforming their data into visual timelines. These visual timelines enable fraud examiners to:

• Highlight key times, dates, and facts.
• More readily determine a sequence of events.
• Analyze multiple or concurrent sequences of events.
• Track unaccounted for time.
• Identify inconsistencies or impossibilities in data.

The Complex Non-Profit

Our Chapter was contacted several weeks ago by the management of a not-for-profit organization seeking a referral to a CFE for conduct of an examination of suspected fraud.  Following a lively discussion with the requester’s corporate counsel, we made the referral which, we’ve subsequently learned, is working out well.  Our discussion of the case with counsel brought the following thoughts to mind. When talking not-for-profits, we’re talking programs; projects that are not funded through the sale of a product or service, but projects that obtain outside funding via the government, charitable grants, or donations to achieve a specific outcome. These outcomes can be any of a variety of things, from a scientific research study to find a cure for a catastrophic illness or federally legislated programs to provide health care to the indigent and elderly, as with the Medicaid and Medicare programs, respectively; or a not-for-profit charity that provides several programs, each funded from different sources, but all providing services to the elderly such as delivered meals, community center operations, adult daycare, and wellness programs. Typically, these outcomes are a social benefit. Some of these programs are of a specific duration, while others are renewed on a periodic basis depending on continued funding and the successful management of the program to achieve the desired outcomes.

In an examination for fraud in such entities, it’s typically not the core projects or programs themselves that are the object of the review; it’s the management of the program. Managers are engaged to operate such programs consistent with the program’s scope and budget. The opportunity for fraud in these programs will vary in several specific aspects: by the independence provided to the program manager, by the organizational structure of the program, and by the level of oversight by the funding source. These three elements make the conduct of a fraud examination of program management different from that of investigations for fraud in the typical core business functions of enterprises like those involved in manufacturing or retail trade. The fraud schemes will be similar because of the ACFE defined primary fraud classifications that apply to almost all organizations, but the key is how they’ve been adapted by program management.

The three primary classifications of fraud that are most common in program management fraud are schemes related to asset misappropriation, corruption, and financial statement reporting.

With asset misappropriation, the fraudulent action most commonly involved is embezzlement, not just simple theft of funds.  While they are both criminal actions, embezzlement has a specific meaning. Black’s Law Dictionary states it best: “the fraudulent taking of private property with which one has been entrusted, especially as a fiduciary.” It really is a matter of intent.
Examples of some inherent fraud schemes and of how these schemes are carried out within a program are:

False expenditures:

— The program is not being conducted, but funds are being expended. This sounds like the classic shell company scam, except a program rather than a for profit business is being exploited. The program by itself is legitimate, but it’s the intent of management that makes it a fraud;

–The program is not performed to its completion; however, the funds are fully expended. The decision to be made is whether the intent was to embezzle funds throughout the program or if there are other underlying reasons as to why the program wasn’t completed that resulted in the embezzlement of the funds;

–The program budget does not allow for program completion. Is this a case of bad budgeting or the use of budgeting with the intent to embezzle;

–The work plan is partially or wholly fictitious. It’s important for the examiner to keep in mind that some programs involve work that is so technologically or scientifically complex that it can be difficult for the examiner to understand just what the objective is.

Overbilling:

Unlike false expenditures, the use of overbilling within programs is more of a means to commit the fraudulent act of embezzlement within the program’s specific functions rather than within the overall program as with false expenditures. Specifically, overbilling schemes are found associated with misuse of time or assets by staff or with expenditures not used in an approved manner. For example:

–Staff members are performing non-program duties. Often, personnel are pulled from one program to work on another. There are many reasons for why this decision is made, but was the funding for that amount of personnel intentionally requested with the purpose of using personnel on another program that is not entitled to receive the funding for additional staff members?

–Staff members are misrepresenting the performance of the program. Often, staff will show the project to be operating on a level that seemingly should require more resources. The project is really operating on a lower level of resources, and whoever has the authority to bill uses that authority to overbill.

–Staff members are hired who are not qualified to perform program duties. Many times, often with large grant monies involved, the program manager hires friends or relatives, or perhaps there is such a strict time frame involved with the funding that management will hire a warm body just to fill the approved slot. In both cases, proper vetting procedures should be in place, even though the granting authority may not require them.

–As with staffing, funds are often redirected to other programs for similar reasons.

–Funds expended are not consistent with the proposed budget. The CFE should ask why the budget is out of line with expenditures? Is the approved budget in use, or was it just prepared as window-dressing for a grant proposal?

–Funds are expended that are not consistent with the governing cost principles. The classic example is the outrageous amounts the military spends on commonly used items, like the $5,000 toilet seat the ACFE originally told us about.

–The program is not completed, but the funding has been expended. Embezzlement can occur within the framework of asset misappropriation or overbilling, but because programs can differ in their objectives to a large degree, the vulnerability is greater to asset misappropriation schemes than to schemes involving overbilling.

Program Reporting:

Financial reporting and program reporting are two different things. Financial reporting can be a component of program reporting, but not the other way around. Many funded projects have strict guidelines on how to report project performance.  Like a disease that goes undetected because everything checked out in a physical exam, ethically challenged program managers find subtle ways to misrepresent performance, either to hide misuse of funds or just to indicate program success when there is none.
For example:

–The status of the project is falsely reported. This type of program reporting misstatement is typically done to give the illusion that the project’s objectives will be met to continue the objective of an uninterrupted steam of funding.

–The program results are falsely reported. The difference between project status and program results may not be apparent at first glance. The motivation is the same in that both are done to hide fraud. The false reporting of program status is typically done to keep funds ongoing throughout the project; the falsification of program results is typically done to ensure renewal of funding for another year or for a period of years. The project type will typically determine the likelihood of which type of false reporting is occurring.

–Improper criteria are used to measure performance. This concerns overall performance as opposed to financial performance. Given that funded projects can be difficult to understand considering the complexity of the activity being performed, performance measurement criteria can be manipulated because of the inherently complicated nature of the basic project. No one understands the project, so how can anyone know whether it’s succeeding? This phenomenon is commonly encountered if the project is divided into so many subparts that no one person, except the project manager, knows with certainty just how it’s proceeding.

–Program accomplishments are falsely reported. How many times have newspapers parroted the declaration from a non-profit that their program provided such and such a level of service to the indigent?  How do readers know if the program’s actual goal (and related funding) wasn’t to provide services to a level of recipients three times the amount reported?

–Operating statistics are manipulated to provide false results. Operating statistics are not financial statistics. An example would be a program that provides meals to the homebound elderly. An amount of payment by those receiving the meals is suggested. However, the government reimbursement for those meals deducts any amount contributed by the elderly being served. The project manager may manipulate the statistics to give more weight to the fixed-income, city-dwelling elderly it services, because such recipients are usually unable to pay anything for their delivered meals.

In summary, in approaching the fraud examination of non-profit entities, it’s not the overall programs themselves that are typically fraudulent, meaning that examinations don’t have to start with a determination of whether the entity is real or a shell. Fraud is committed by people, not programs or business systems; they are the tools of fraud. The ultimate funding source of programs are people as well, whether taxpayers (in the case of Federal or State governments) or private citizens (in the case of private charities).   It is not only the vast amount of funding that can flow to not-for-profit programs that constitutes the justification for combating fraud committed by the management of such programs. Programs that rely on funding as non-profits are typically entities that are established to provide a public benefit; to fill in the gaps for services and products not provided through any other means. So, the occurrence of fraud in these programs, no matter the size of the program or the fraud, is an especially heinous act given the loss of social benefit that results. For that reason alone, the examination of program management by CFEs is vital to the public interest.