Category Archives: Fraud Prevention

Program Integrity Federalism

Posted by on July 15, 2019 Comments Off on 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?

Posted by on April 29, 2019 Comments Off on 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!

Cash In – Cash Out

Posted by on April 9, 2019 Comments Off on 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.

Inflexible Reporting

Posted by on March 11, 2019 Comments Off on Inflexible Reporting

Our Chapter and the ACFE have published a number of articles and posts over the last few years about the various types of pressures that can push ethically challenged employees over the line between temptation and the perpetration of an actual accounting fraud. One category of such pressure stems directly from the nature of our present system of periodic financial reporting which, it can be argued, not only creates unnecessary volatility in the stock and financial markets but ends up requiring rational investors to demand a premium for securities investments by emphasizing the short term risk that near term, inflexable, quarterly earnings targets will not be met. The pressure to meet these short term targets can only give rise to operational inefficiencies which in turn drive up the inherent inefficiency in the transmission of information from public companies to financial markets based on a model which hasn’t changed much since its original definition during the Great Depression years of the 1930’s.

I’ve seen articles in the Journal of Accountancy and in other authoritative financial publications pointing toward a better way and, with the advent of and widening support for the electronic reporting of financial results to the SCC (the XBRL initiative), we can hope we’re well into the drawn of a new age. That there’s been pushback to this effort is understandable. Those familiar with the technical and professional minefield of the present quarterly reporting process can only feel sympathy with those financial officers who have to go through it, quarter by quarter and year after year. Questions originally abounded about process and mechanics like how is electronically published financial information going to be verified and what real controls are there over its reliability? What happens if there’s an honest mistake?

Think about all this from the point of view of the fraud examiner. If enterprises, listed and non-listed, can make the transition from a periodic to a real-time, electronic based financial reporting system, the resulting efficiencies and the decrease in numerous types of fraud related risk would be truly striking. Real-time financial reporting would free our clients from the tyranny of the present, economically nonsensical, reporting of quarterly results. How much of the incentive to commit financial fraud to meet the numbers does that immediately alleviate? As one financial expert after another has pointed out over the years, there’s just no justification for focusing on a calendar quarter as the unit in which to take stock of financial performance, beyond the fact that that’s what’s presently codified in the law. By contrast, what if financial information were published and available to all users on a real-time basis? The immediate availability of such information, continuously updated, on whatever basis is appropriate for the individual enterprise and its industry, would force companies to adopt a reporting unit that ready makes sense to them and to their principal information users. For some companies that unit might be a week, a month, a quarter, semi-annually or a year. So be it. Let a thousand flowers bloom; the upshot is that what would end up being reported would make sense for the company, its industry and for the information users rather than the one-size fits all, set in stone, prescription of the present law.

An additional advantage, and one with immediate implications for fraud prevention, would be the opportunity for increased efficiency in financial markets as investment dollars could be allocated not according to quarterly results or according to the best guess estimates of financial analysts, but by reliable financial information provided directly by the company all the time; goodbye to many of the present information control vulnerabilities that support insider trading because information is not widely and efficiently disseminated. The point is that by employing digital, cloud-based analytics report building tools properly, users of all kinds could customize a set of up-to-date financial reports (in whatever format) on whatever time period, that suits their fancy.

But many have also pointed out that if there is to be such a shift from periodic to real-time financial reporting, there needs to be a fundamental change in basic attitudes toward financial reporting. Those who report and those who inspect financial information will have to change their focus from methods by which the numbers themselves are checked (audited) to methods (as with XBRL) that focus on the reliability of the system that generates the numbers. That’s where fraud examiners and other financial insurance professionals come in. On-line financial information will be published with such frequency and so rapidly, that there will be no time to “check” individual numbers; the emphasis for assurance professionals will, therefore, need to shift away from checking numbers and balances to analysis of and reporting on the integrity of the system of internal controls over the reporting system itself; understanding of the details of the internal control system over financial reporting will gain a level of prominence it’s never had before.

Fraud examiners need to be aware of these issues when counseling clients about the profound impact that digitally based, on-line reporting of financial information is and will have on their fraud prevention and fraud risk assessment programs. As with all else in life, real time financial reporting will inevitably decrease the risk of some fraud scenarios and increase the risk of others.

Matching SOCS

Posted by on February 25, 2019 Comments Off on Matching SOCS

I was chatting with the soon-to-be-retired information systems director of a major Richmond insurance company several nights ago at the gym. Our friendship goes back many years to when we were both audit directors for the Virginia State Auditor of Public Accounts. My friend was commenting, among other things, on the confusing flood of regulatory changes that’s swept over his industry in recent years relating to Service Organization Controls (SOC) reports. Since SOC reports can be important tools for fraud examiners, I thought they might be an interesting topic for a post.

Briefly, SOC reports are a group of internal control assurance reports, performed by independent reviewers, of IT organizations providing a range of computer based operational services, usually to multiple client corporations. The core idea of a SOC report is to have one or a series of reviews conducted of the internal controls related to financial reporting of the service organization and to then make versions of these reports available to the independent auditors of all the service organization’s user clients; in this way the service organization doesn’t have to be separately and repeatedly audited by the auditors of each of its separate clients, thereby avoiding much duplication of effort and expense on all sides.

In 2009 the International Auditing and Assurance Standards Board (IAASB) issued a new International Standard on Assurance Engagements: ‘ISAE 3402 Assurance Reports on Controls in a Service Organization’. The AICPA followed shortly thereafter with a revision of its own Statement on Auditing Standards (SAS) No. 70, guidance around the performance of third party service organization reports, releasing Statement on Standards for Attestation Engagement (SSAE) 16, ‘Reporting on Controls in a Service Organization’. So how does the SOC process work?

My friend’s insurance company (let’s call it Richmond Mutual) outsources (along with a number of companion companies) its claims processing functions to Fiscal Agent, Ltd. Richmond Mutual is the user organization and Fiscal Agent, Ltd is the service organization. To ensure that all the claims are processed and adequate internal controls are in place and functioning at the service organization, Richmond Mutual could appoint an independent CPA or service auditor to examine and report on the service organization’s controls. In the case of Richmond Mutual, however, the service organization itself, Fiscal Agent, Ltd, obtains the SOC report by appointing an independent service auditor to perform the audit and provide it with a SOC 1 report. A SOC 1 report provides assurance on the business processes that support internal controls over financial reporting and is, consequently, of interest to fraud examiners as, for example, an element to consider in structuring the fraud risk assessment. This report can then be shared with user organizations like Richmond Mutual and with their auditors as deemed necessary. The AICPA also provides for two other SOC reports: SOC 2 and SOC 3. The SOC 2 and SOC 3 reports are used for reporting on controls other than the internal controls over financial reporting. One of the key differences between SOC 2 and SOC 3 reports is that a SOC 3 is a general use report to be provided to anyone while SOC 2 reports are only for those users specifically specified in the report; in other words, the distribution is limited.

SOC reports are valuable to their many users for a whole host of obvious reasons but Fraud Examiners and other assurance professionals need to keep in mind some common misconceptions about them (some shared, I found, by my IT friend). SOC reports are not assurances. IASSB and AICPA guidelines specify that SOC reports are to be of limited distribution, to be used by the service organization, user organization and user auditors only and thus should never be used for any other service organization purpose; never, for example, as marketing or advertising tools to assure potential clients of service organization quality.

SOC 1 reports are used only for reporting on service organization internal controls over financial reporting; in cases where a user or a service organization wants to assess such areas as data privacy or confidentiality, they need to arrange for the performance of a SOC 2 and/or SOC 3 report.

It’s also a common mistake to assume that the SOC report is sufficient verification of internal controls and that no controls on the user organization side need to be assessed by the auditors; the guidelines are clear that while verifying controls at the service organization, controls at the user organization should also be verified. Since service the organization provides considerable information as background for the service auditor’s review, service organizations are often under the mistaken impression that the accuracy of this background information will not be evaluated by the SOC reviewer. The guidelines specify that SOC auditors should carefully verify the quality and accuracy of the information provided by the service organization under the “information provided by the service organization” section of their audit program.

In summary, the purpose of SOC 1 reports is to provide assurance on the processes that support internal controls over financial reporting. Fraud examiners and other users should take the time to understand the varied purpose(s) of the three types of SOC reports so they can use them intelligently. These reports can be extremely useful to fraud examiners assessing the fraud enterprise risk prevention programs of user organizations to understand the controls that impact financial operations and related IT controls, especially in multiple-service provider scenarios.

Sniffing it Out

Posted by on February 18, 2019 Comments Off on Sniffing it Out

The first Virginia governor I worked for directly was John Dalton, who was fond of saying that his personal gauge for ethically challenged behavior was the smell test, i.e., did any proposed action (and its follow-on implications) have the odor of appropriateness. Philosophical theories provide the bases for most useful practical decision approaches and aids, although a majority of seasoned executives are unaware of how and why this is so. Whatever the foundation of the phenomena may be, most experienced directors, executives, professional accountants (and governors) appear to have developed tests and commonly used rules of thumb that can be used to assess the ethicality of decisions on a preliminary basis.

If these preliminary tests give rise to concerns, most think a more thorough analysis should be performed. It is often appropriate (and quite common in practice) for subordinate managers and other employees to be asked to check a proposed decision in a quick, preliminary manner to see if an additional full-blown ethical or practicality analysis is required. These quick tests are often referred to as sniff tests. If any of these quick tests are negative, employees are asked to seek out someone like the corporate counsel or an ethics officer (if there is one) for consultation, or to personally perform a full-blown analysis of the proposed action. This analysis is usually retained, and perhaps even reviewed by upper management.

Some of the more common sniff tests employed by managers with whom I’ve worked are:

–Would I be comfortable if this action or decision were to appear on the front page of a national newspaper tomorrow morning?
Will I be proud of this decision?
Will my mother and father be proud of this decision?
Is this action or decision in accord with the corporation’s mission and code?
Does this feel right to me?

Unfortunately, although sniff tests and commonly used ethical rules of thumb are based on ethical principles as popularly conceived and are often useful, they rarely, by themselves, represent anything approaching a comprehensive examination of the confronting decision and therefore can leave the individuals and organization(s) involved vulnerable to making a challengeable choice. For this reason, experts advise that more comprehensive techniques of evaluation should be employed whenever a proposed decision is questionable or likely to have significant consequences. Analysis of specific sniff tests and the related heuristics reveals that they usually focus on a fraction of the comprehensive set of criteria that more complete forms of analysis examine.

Traditionally, an accepted business school case approach to the assessment of a corporate decision and the resulting action has been to evaluate the end results or consequences of the action. To most businesspeople, this evaluation has traditionally been based on the decision’s impact on the interests of the company’s owners or shareholders.

Usually these impacts have been measured in terms of the profit or loss involved, because net profit has been the measure of well-being that shareholders have wanted to maximize. This traditional view of corporate accountability has been modified over the last two decades in two ways. First, the assumption that all shareholders want to maximize only short-term profit appears to represent too narrow a focus. Second, the rights and claims of many non-shareholder groups, such as employees, consumers/clients, suppliers, lenders, environmentalists, host communities, and governments that have a stake or interest in the outcome of the decision, or in the company itself, are being accorded an increased status in corporate decision making.

Modern corporations are increasingly declaring that they are holding themselves self -accountable to shareholders and to non-shareholder groups alike, both of which form the set of stakeholders to which the company pledges to respond. It has become evident (look at the Enron example) that a company cannot reach its full potential, and may even perish, if it loses the support of even one of a select set of its stakeholders known as primary stakeholders.

The assumption of a monolithic shareholder group interested only in short-term profit is undergoing modification primarily because modem corporations are finding their shareholders are to an increasing degree made up of persons and institutional investors who are interested in longer-term time horizons and in how ethically individual businesses are conducted. The latter, who are referred to as ethical investors, apply two screens to investments: Do the investee companies make a profit in excess of appropriate hurdle rates, and do they strive to earn that profit in a demonstrably ethical manner?

Because of the size of the shareholdings of mutual and pension funds, and of other types of institutional investors involved, corporate directors and executives have found that the wishes of ethical investors can be ignored only at their peril. Ethical investors have developed informal and formal networks through which they inform themselves about corporate activity, decide how to vote proxies, and how to approach boards of directors to get them to pay attention to their concerns in such areas as environmental protection, excessive executive compensation, and human rights activities in specific countries and regions. Ethical investors as well as other stakeholder groups, tend to be increasingly unwilling to squeeze the last ounce of profit out of the current year if it means damaging the environment or the privacy rights of other stakeholders. They believe in managing the corporation on a broader basis than short-term profit only. Usually the maximization of profit in a longer than one-year time frame requires harmonious relationships with most stakeholder groups based on the recognition of the interests of those groups.

A negative public relations experience can be a significant and embarrassing price to pay for a decision making process that fails to take the. wishes of stakeholder groups into account. Whether or not special interest groups of private citizens are also shareholders, their capacity to make corporations accountable through social media is evident and growing. The farsighted executive and director will want these concerns taken into account before offended stakeholders have to remind them.

Taking the concerns or interests of stakeholders into account when making decisions, by considering the potential impact of decisions on each stakeholder, is therefore a wise practice if executives want to maintain stakeholder support. However, the multiplicity of stakeholders and stakeholder groups makes this a complex task. To simplify the process, it is desirable to identify and consider a set of commonly held or fundamental stakeholder interests to help focus analyses and decision making on ethical dimensions; stakeholder interests such as the following:

1.Their interest(s) should be better off as a result of the decision.
2. The decision should result in a fair distribution of benefits and burdens.
3. The decision should not offend any of the rights of any stakeholder, including the decision maker, and ..
4. The resulting behavior should demonstrate duties owed as virtuously as expected.

To some extent, these fundamental interests have to be tempered by the realities facing decision makers. For example, although a proposed decision should maximize the betterment of all stakeholders, trade-offs often have to be made between stakeholders’ interests. Consequently, the incurrence of pollution control costs may be counter to the interests of short-term profits that are of interest to some current shareholders and managers. Similarly, there are times when all stakeholders will find a decision acceptable even though one or more of them, or the groups they represent, may be worse off as a result.

In recognition of the requirement for trade-offs and for the understanding that a decision can advance the well-being of all stakeholders as a group, even if some individuals are personally worse off, this fundamental interest should be modified to focus on the well-being of stakeholders rather than only on their betterment. This modification represents a shift from utilitarianism to consequentialism. Once the focus on betterment is relaxed to shift to well-being, the need to analyze the impact of a decision in terms of all four fundamental interests becomes apparent. It is possible, for example, to find that a proposed decision may produce an overall benefit, but the distribution of the burden of producing that decision may be so debilitating to the interests of one or more stakeholder groups that it may be considered grossly unfair. Alternatively, a decision may result in an overall net benefit and be fair, but may offend the rights of a stakeholder and therefore be considered not right. For example, deciding not to recall a marginally flawed product may be cost effective, but would not be considered to be right if users could be seriously injured. Similarly, a decision that does not demonstrate the character, integrity, or courage expected will be considered ethically suspect by stakeholders.

A professional CFE can use an assessment of our client organization’s stakeholder ethical concerns in making pro-active recommendations about fraud detection and prevention strategies and in conducting investigations and should be ready to prepare or assist in such assessments for employers or clients just as they currently do in other fraud deterrence related business processes.

Although many hard-numbers-oriented investigators will be wary of becoming involved with the soft risk assessment of management’s tone-at-the-top ethically shaped decisions, they should bear in mind that the world is changing to put a much higher value on the quality and impact of management’s whole governance structure, the posture of which cannot failure to negatively or positively affect the design of the client’s fraud control and prevention programs.

Ambiguous Transactions

Posted by on February 11, 2019 Comments Off on Ambiguous Transactions

As any experienced fraud examiner will be happy to tell you, unambiguously distinguishing individual instances of fraud, waste and abuse, one from the other, can be challenging; that’s because transactions demonstrating characteristics of one of these issues so often share characteristics of the other(s). A spate of recent articles in the trade press confirm the public impression not only that health care costs are constantly rising but that poorly controlled health care provider reimbursement systems represent significant targets of waste and abuse, both within companies themselves and from external bad actors.

While some organizations review their health benefits programs and health administrator organizations annually, others appear to be doing relatively little in this area. Consequently, CFEs are increasingly being asked as audit team members to participate in fraud risk assessments of hearth benefits administration (HBA) programs for corporations, government entities, and nonprofit organizations. As a consequence, ACFE members are increasingly identifying practices that result in recoverable losses as well as losses that were never recovered because some among our client organizations have never effectively audited their health benefit plans.

A good place to start with this type of fraud risk assessment is for the CFE to evaluate the oversight of HBA reporting activities that could identify unidentified losses for the client organization.

Many organizations contract with third-party administrators (TPAs) to oversee their employee insurance claims process, health care provider network, care utilization review, and employee health plan membership functions. In the arena of claims processing, in today’s environment of rising costs, TPAs can make significant claim payment errors that result in financial losses to the CFE’s client organization if such errors are not promptly identified, recovered, and credited back to the plan. Claim overpayments are common in the industry; and most TPAs themselves have audit processes in place to minimize the losses to their clients. Many control assurance professionals incorrectly assume that the claim audit covers all the exposures, as the primary function of claims administration is to pay claims. This misconception can block a true understanding of the nature of the exposures and lessen the client’s sense of the necessity that systematic fraud and waste detection audits of health care claims transactions are performed, both externally and internally.

The trade press recently reported that an administrator for a U.S. federal government health benefit’s health plan changed its method of administering coordination of benefits (COB) from “pursue and pay” to “pay and pursue.” Under “pursue and pay,” the administrator determines who the primary insurance payer is before making payment. Under “pay and pursue,” the administrator pays the insurance claim and pursues a refund only if it itself is determined to be the secondary payer. In this case, the clients were billed for the payment of full benefits, even though they should have been the secondary payers. The financially strapped administrator recovered the overpayments, deposited them into a bank account, and never credited its clients. Following an audit, one of the client plans received a check for $2.3 million for its share of the refunds that were not returned to it. Is this case of apparent deception an example of fraud? Of waste? Or of abuse?

If COB savings had been routinely monitored by each of the plans, along with each client’s other cost containment activities, they would have noticed that the COB savings had fallen off and were next to nothing under “pay and pursue.” When looking at COB, CFEs and client internal auditors should review the provisions of the contract with the administrator to determine who is responsible for identifying other group coverage (OGC), the methodology for investigating OGC, time limitations for recovering overpayments, and the requirements for the reporting of savings to the client organization by the administrator. In conducting their risk assessments, client management and CFEs also should consider the controls over the organization’s oversight of monitoring COB savings and over the other cost containment activities performed by the administrator.

The COB case considered above was intentional deception, but losses also can be unintentional. To recover overpayments, the TPA can use a refund request letter to request refunds from healthcare providers (hospitals, physicians, etc.), or use the provider offset method, which deducts the overpayment from the provider’s next payment. The ACFE has reported one case in which a provider voluntarily returned an overpayment. The administrator’s policy was to return the refund check to the submitting provider with a form to complete including instructions to send the form and the check back to the administrator to initiate a provider offset on the next payment to the provider. No logs were kept of the checks received and returned to the providers. Following an audit, the client found that, because of a lack of training, personnel of its administrator had deposited the returned checks from providers into an administrative holding account. Subsequent to the investigation and administrative staff training, the client’s refund activity increased from almost nothing to more than $1 million a year. Including the monitoring and analyzing of refund activity as a component of the fraud prevention program will unfailingly provide insight into how well claim overpayments are being controlled.

When assessing for fraud risk regarding refund activity for health insurance overpayments, CFEs should pay attention to the collection methods used by the administrator, overpayment amounts and time limitations for recovery, and the use of external vendors and their shared savings on recoveries. Reporting from the administrator should be required to include an analysis of refund activity, the reasons for the refund(s), breakout between solicited and unsolicited refunds, and the balance of outstanding refunds.

Sometimes it cannot be determined whether an organization’s losses are intentional or unintentional. For example, in one review, several organizations contracted with a marketing firm specializing in a new approach to control health-care costs. The marketing firm hired an administrator to process the claims for its clients. After four months with the firm, an alert accountant at one of the organizations questioned why funding requests coming from the marketing firm were running 20 percent higher each month than they had been with the previous administrator. The organization’s finance division requested a review which revealed that the marketing firm had been billing its clients based on claims processed by the administrator, including claims not paid. The firm insisted it had not been aware that the funding requests resulted in client overbilling and agreed to refund the overbilled amounts to the organization.

Monitoring and approving the funding requests against some measure of expected costs can identify when costs should be investigated. When reviewing funding requests, assurance professionals should pay attention to the internal funding approval process, supporting detail provided by the administrator to support the funding, funding limitation controls to identify possible overfunding for follow-up investigation, bank account setup and account access, and the internal funding reconciliation process.

While losses may occur because of the administrator’s practices, losses (waste) also can go undetected because the organization does not perform adequate oversight of the practices used on its accounts. Preferred provider organization (PPO) discounts are common in managed health care plans. When organizations use PPO networks that are independent of the administrator’s contracted network, the PPO networks receive the claim first to reprice it with the negotiated rate. The PPO network generates a repricing sheet, which is sent with the original claim to the administrator for processing and payment.

In one case, no one explained the repricing sheets to the claim examiners, so they ignored them. The claims system automatically priced and loaded the administrator’s network claims with the negotiated rates into the claims system. However, because the client’s external PPO network fees were not in the claims system, the claims were paid at billed charges. The client lost an estimated $750,000 in discounts over a one-year period and was paying 34 percent of the savings to the PPO networks for savings that it never received. The client did not detect the lost discounts because it never reconciled the discounts reported by the PPO’s quarterly billings for its share of the savings to a discount savings as reported by the administrator.

While examining risks regarding discounts, CFE’s auditors should review the administrator’s or independent PPO network’s contracts regarding PPO pricing and access to pricing variation for in-network provider audits, alternative savings arrangements using external vendors for out-of-network providers, and reporting of PPO discount savings. Within their own organizations, auditors should be instructed to review the internal process of monitoring discount reporting and reconcile PPO shared savings to the administrator reporting the discounts.

There are frequent reports on fraud, abuse, and errors in government health programs issued by the U.S. Department of Health and Human Services’ Office of the Inspector General and by the U.S. Government Accountability Office; all these reports can be of use to CFEs in the conduct of our investigations. Because many of our client organization’s health plans mirror government programs, the fraud risk exposure in organizations is almost everywhere the same. Organizations have incurred tremendous losses by not systematically reviewing benefits administration and through lack of understanding of the dynamics of health plan oversight within their organizations. Developing and promoting a team response within an organization to foster understanding of the exposures in the industry is a practical role for all CFEs. This posture puts fraud examiners (as members of the fraud/abuse prevention and response team) in a position to provide management with assurance that the reporting on the millions spent on employees’ health benefits is accurate and reasonable and that associated costs are justified.

Detect and Prevent

Posted by on January 14, 2019 Comments Off on 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.

Risk-Centric Fraud Prevention

Posted by on December 17, 2018 Comments Off on Risk-Centric Fraud Prevention

A number of our certified Chapter members, currently practicing both independently and as corporate staff, report being asked to proactively assist in the establishment of first time internal fraud prevention programs by clients and employers. That this development is something new is borne out by recent articles in the trade press but, on a moment’s reflection, shouldn’t be surprising since CFEs are so uniquely qualified for the particular task.

At a time when an increasingly volatile stock environment, increased cases of cyber fraud, the pressure of globalization and a multitude of increased regulatory requirements are of major concern to all managements, risk assessment and fraud prevention really have to play an important role in ensuring that corporations are not exposed to unexpected and poorly controlled risks. Internal fraud prevention related activities need to be revisited with a focus not just on all these new business paradigms but also on stakeholders’ expectations, transparency, and accountability.

It just makes sense then that today’s environment also calls for greater collaboration and strong relationships between all types of assurance professionals with their clients at all levels to ensure an internal anti-fraud structure is in place (if one doesn’t presently exist) that facilitates a healthy, secure and transparent operating environment.

To facilitate the establishment of a risk-centric approach, today’s fraud prevention functions (new or presently existing) must continually revisit their methodologies, processes, and practices. CFEs can provide experienced insight and real-time value to their client organization by expanding their consulting efforts to facilitate a risk-centric approach, helping to establish the foundation for a more sophisticated and nimble tone at the top, and by focusing on increased collaboration and strategic engagement.

Fraud prevention efforts have been dominated for some time now by a control focused approach that is often reactive and regressive in actual practice in the face of today’s swiftly changing realities. Anti-fraud professionals today need to widen their proactive scope to address the growing governance threats and risk management needs of increasingly global organizations. This requires them to adopt a revised risk-centric approach that involves:

–Taking fraud prevention and business ethics from a compliance perspective to a cultural mind-set. Accurately assessing these risks requires more than just checking to see whether rules are being followed; practitioners must also try to ensure that the spirit of these rules is incorporated into activities at every level.

–Determining key business and fraud risks rather than casting a wide net over numerous risks, many of which may be remote or obscure; the concept of critical business process identification drawn from disaster recovery and continuous operations planning is especially relevant here.

–Identifying emerging risk issues and trends, such as changes in the regulatory environment (which are often wholly reactive), and bringing them to the attention of key stakeholders.

–Estimating the significance of each fraud risk and assessing its probability of occurrence based on a deeper understanding of the present sense conveyed by constantly shifting data and as sometimes pinpointed by sophisticated statistical analysis.

–Identifying programs and controls designed to more sensitively detect and address risk and by concurrent testing of their effectiveness in real-time.

–Coordinating with the other critical risk and control related business processes, such as compliance, risk management, fiscal control, and legal, to ensure that fraud risks are identified, controlled and managed appropriately.

To provide real strategic value to the organization, new and existing fraud prevention practitioners need to help develop risk-based action plans that respond to their present state of risk assessment awareness and which focus on stakeholder expectations. Internal anti-fraud plans should incorporate risk identification and prioritization, as well as analysis and quantification of risk factors particularly in the new business ventures and strategies so characteristic of today’s volatile environment. Such planning should also reflect an understanding of shared risks among various projects and initiatives, and feature continuous monitoring of business activities and key performance indicators.

In the present cyber-threat laden environment the internal fraud prevention business process has to move from being just another routine and disconnected function to being a fulcrum of organizational governance and risk, working in concert with management, the board, and external auditors. Top management can establish the fraud prevention function’s role by:

–Allowing senior fraud examiners and investigators exposure to security information presently associated with key management and governance committees;
–Championing the importance of ethical conduct, fraud identification and fraud prevention consistently.
–Taking immediate and proactive action on fraud examination and investigative findings regardless of whatever level of the organization suspected perpetrators are identified.
–Holding senior executives accountable for identified instances of fraud, waste and abuse in business processes over which they exercise management oversight.
–Supporting the management of the fraud prevention function when its findings and recommendations to improve security prove politically unpopular.
–Defining fraud prevention’s role and management’s expectations.
–Providing appropriate funding, talent and authority to the function.

The ACFE has long indicated that a strong tone at the top from senior management about the importance of a internal fraud prevention function goes a long way toward promoting the engagement of managers throughout the client organization.

For staff assigned to an internal fraud prevention plan to proactively review important business strategies successfully for fraud vulnerability, examiners need to collaborate with management. In addition to providing assurance on compliance initiatives, examiners should develop a forward-looking approach to their assessment planning in which they cooperate and coordinate with related risk and control functions, focus on critical business risks and exposures, and determine the relevance and effectiveness of gathered executive responses to help an organization manage fraud risk proactively. To be forward-looking, fraud prevention professionals need to be fully integrated into the strategic planning process so that they can clearly identify which fraud related risks the organization will be undertaking. They also must be involved with the business in evaluating problems that come to light to determine whether they are the result of control weaknesses that could also emerge in other parts of the organization.

To identify and analyze rapidly emerging risks, direct resources toward areas of greatest risk, and conduct targeted, real-time investigations in response to specific, predicated risks, examiners must leverage technology, learn new skills, and work with management to understand and clarify their evolving expanded role.

To assess the new emerging risks effectively, fraud prevention professionals must develop a deeper understanding of the client business and of the processes that make competitors in the client’s industry successful. An effective fraud prevention activity that can deal with contemporary business risks and meet the ever-increasing demands of management and stakeholders requires a solid staffing strategy. As CFEs we must help spread the word that our client organizations need to invest in skilled resources, methods, training, career paths, and technical infrastructure to deal with increasing cyber-related business risks related to fraud, their internal controls, and government imposed regulations. When staffing a fraud prevention function, top management should:

–Establish a program for selecting and developing the fraud prevention team.
–Identify the skills and expertise required for an effective anti-fraud business process; the ACFE’s guidance and training programs are an invaluable resource to any organization contemplating a new fraud prevention function or looking to strengthen an existing one.
–Assess existing resources to identify staffing gaps.
–Identify and create key performance indicators for deploying fraud prevention and investigatory resources.
–Co-source or outsource internal fraud prevention activities, based on an assessment of current resources, budget, and strategic and tactical requirements.

Acquiring new skills through ACFE training can enable internally focused examiners to direct resources to those techniques that are the most effective in identifying risks to the organization. Especially important is the need to develop deep expertise in specialties such as credit, IT, finance, compliance, and cyber. In addition, investigators and examiners will have to be trained to approach their work strategically, beginning with a detailed understanding of where its owners and stakeholders view where the client business has been and where it is going.

In summary, progressive internal fraud prevention and investigation functions need to partner with their client organization’s risk management function to gain comprehensive visibility into enterprise-wide risks and to support performance of automation supported follow-on risk assessments that can help prevent fraud vulnerability issues from turning into fraud events. Such insight into the organization’s risk profile allows internal investigative professionals to deliver more strategic value by focusing their proactive fraud risk evaluation efforts on areas that represent the greatest risk to the organization as well as proactively anticipating where emerging fraud risk issues are most likely to cause problems. In addition, leveraging the activities performed by the client’s risk management function can lower fraud prevention’s overall cost of operation.

Cloud Shapes

Posted by on November 12, 2018 Comments Off on Cloud Shapes

Just as clouds can take different shapes and be perceived differently, so too is cloud computing perceived differently by our various types of client companies. To some, the cloud looks like web-based applications, a revival of the old thin client. To others, the cloud looks like utility computing, a grid that charges metered rates for processing time. To some, the cloud could be parallel computing, designed to scale complex processes for improved efficiency. Interestingly, cloud services are wildly different. Amazon’s Elastic Compute Cloud offers full Linux machines with root access and the opportunity to run whatever apps the user chooses. Google’s App Engine will also let users run any program they want, as long as the user specifies it in a limited version of Python and uses Google’s database.

The National Institute of Standards and Technology (NIST) defines cloud computing as a model for enabling convenient, on-demand network access to a shared pool of configurable computing resources (e.g., networks, servers, storage, applications, services) that can be rapidly provisioned and released with minimal management effort or service provider interaction. It is also important to remember what our ACFE tells us, that the Internet itself is in fact a primitive transport cloud. Users place something on the path with an expectation that it will get to the proper destination, in a reasonable time, with all parties respecting the privacy and security of the artifact.

Cloud computing, as everyone now knows, brings many advantages to users and vendors. One of its biggest advantages is that a user may no longer have to be tethered to a traditional computer to use an application, or have to buy a version of an application that is specifically configured for a phone, a tablet or other device. Today, any device that can access the Internet can run a cloud-based application. Application services are available independent of the user’s home or office devices and network interfaces. Regardless of the device being used, users also face fewer maintenance issues. End users don’t have to worry about storage capacity, compatibility or other similar concerns.

From a fraud prevention perspective, these benefits are the result of the distributed nature of the web, which necessitates a clear separation between application and interaction logic. This is because application logic and user data reside mostly on the web cloud and manifest themselves in the form of tangible user interfaces at the point of interaction, e.g., within a web browser or mobile web client. Cloud computing is also beneficial for our client’s vendors. Businesses frequently find themselves using the vast majority of their computing capacity in a small percentage of time, leaving expensive equipment often idle. Cloud computing can act as a utility grid for vendors and optimize the use of their resources. Consider, for example, a web-based application running in Amazon’s cloud. Suppose there is a sudden surge in visitors as a result of media coverage, for example. Formerly, many web applications would fail under the load of big traffic spikes. But in the cloud, assuming that the web application has been designed intelligently, additional machine instances can be launched on demand.

With all the benefits, there are related constraints. Distrust is one of the main constraints on online environments generally. particularly in terms of consumer fraud, waste and abuse protection. Although the elements that contribute to building trust can be identified in broad terms, there are still many uncertainties in defining and establishing trust in online environments. Why should users trust cloud environments to store their personal information and to share their privacy in such a large and segregated environment? This question can be answered only by investigating these uncertainties in the context of risk assessment and by exploring the relationship between trust and the way in which the risk is perceived by stakeholders. Users are assumed to be willing to disclose personal information and have that information used subsequently to store their personal data or to create consumer profiles for business use when they perceive that fair procedures are in place to protect their individual privacy.

The changing trust paradigm represented by cloud computing means that less information is stored locally on our client’s machines and is instead being hosted elsewhere on earth. No one for the most part buys software anymore; users just rent it or receive it for free using the Software as a Service (SaaS) business model. On the personal front, cloud computing means Google is storing user’s mail, Instagram their photographs, and Dropbox their documents, not to mention what mobile phones are automatically uploading to the cloud for them. In the corporate world, enterprise customers not only are using Dropbox but also have outsourced primary business functions that would have previously been handled inside the company to SaaS providers such as Salesforce.com, Zoho.com, and Box.com.

From a crime and security perspective, the aggregation of all these data, exabytes and exabytes of it, means that user’s most personal of information is no longer likely stored solely on their local hard drives but now aggregated on computer servers around the world. By aggregating important user data, financial and otherwise, on cloud-based computer servers, the cloud has obviated the need for criminals to target everybody’s hard drive individually and instead put all the jewels in a single place for criminals and hackers to target (think Willie Sutton).

The cloud is here to stay, and at this point there is no going back. But with this move to store all available data in the cloud come additional risks. Thinking of some of the largest hacks to date, Target, Heartland Payment Systems, TJX, and Sony PlayStation Network; all of these thefts of hundreds of millions of accounts were made possible because the data were stored in the same virtual location. The cloud is equally convenient for individuals, businesses, and criminals.

The virtualization and storage of all of these data is a highly complex process and raises a wide array of security, public policy, and legal issues for all CFEs and for our clients. First, during an investigation, where exactly is this magical cloud storing my defrauded client’s data? Most users have no idea when they check their status on Facebook or upload a photograph to Pinterest where in the real world this information is actually being stored. That they do not even stop to pose the question is a testament to the great convenience, and opacity, of the system. Yet from a corporate governance and fraud prevention risk perspective, whether your client’s data are stored on a computer server in America, Russia, China, or Iceland makes a difference.

ACFE guidance emphasizes that the corporate and individual perimeters that used to protect information internally are disappearing, and the beginning and end of corporate user computer networks are becoming far less well defined. It’s making it much harder for examiners and auditors to see what data are coming and going from a company, and the task is nearly impossible on the personal front. The transition to the cloud is a game changer for anti-fraud security because it completely redefines where data are stored, moved, and accessed, creating sweeping new opportunities for criminal hackers. Moreover, the non-local storage of data raises important questions about deep dependence on cloud-based information systems. When these services go down or become unavailable i.e., a denial of service attack, or the Internet connection is lost, the data become unavailable, and your client for our CFE services is out of business.

All the major cloud service providers are routinely remotely targeted by criminal attacks, including Dropbox, Google, and Microsoft, and more such attacks occur daily. Although it may be your client’s cloud service provider that is targeted in such attack, the client is the victim, and the data taken is theirs’s. Of course, the rights reserved to the providers in their terms of service agreements (and signed by users) usually mean that provider companies bear little or no liability when data breaches occur. These attacks threaten intellectual property, customer data, and even sensitive government information.

To establish trust with end users in the cloud environment, all organizations should address these fraud related risks. They also need to align their users’ perceptions with their policies. Efforts should be made to develop a standardized approach to trust and risk assessment across different domains to reduce the burden on users who seek to better understand and compare policies and practices across cloud provider organizations. This standardized approach will also aid organizations that engage in contractual sharing of consumer information, making it easier to assess risks across organizations and monitor practices for compliance with contracts. policies and law.

During the fraud risk assessment process, CFEs need to advise their individual corporate clients to mandate a given cloud based activity in which they participate to be conducted fairly and to address their privacy concerns. By ensuring this fairness and respecting privacy, organizations give their customers the confidence to disclose personal information on the cloud and to allow that information subsequently to be used to create consumer profiles for business use. Thus, organizations that understand the roles of trust and risk should be advised to continuously monitor user perceptions to understand their relation to risk aversion and risk management. Managers should not rely solely on technical control measures. Security researchers have tended to focus on the hard issues of cryptography and system design. By contrast. issues revolving around the use of computers by lay users and the creation of active incentives to avoid fraud have been relatively neglected. Many ACFE lead studies have shown that human errors are the main cause of information security incidents.

Piecemeal approaches to control security issues related to cloud environments fail simply because they are usually driven by a haphazard occurrence; reaction to the most recent incident or the most recently publicized threat. In other words, managing information security in cloud environments requires collaboration among experts from different disciplines, including computer scientists. engineers. economists, lawyers and anti-fraud assurance professionals like CFE’s, to forge common approaches.