Category Archives: Fraud Response

Charting the Road Ahead

There are a number of good reasons why fraud examiners and forensic accountants should work hard at including inclusive, well written descriptions of fraud scenarios in their reports; some of these reasons are obvious and some less so. A well written fraud report, like little else, can put dry controls in the context of real life situations that client managers can comprehend no matter what their level of actual experience with fraud. It’s been my experience that well written reports, couched in plain business language, free from descriptions of arcane control structures, and supported by hard hitting scenario analysis can help spark anti-fraud conversations throughout the whole of a firm’s upper management.

A well written report can be a vital tool in transforming that discussion from, for example, relatively abstract talk about the need for an identity management system to a more concrete and useful one dealing with the report’s description of how the theft of vital business data has actually proven to benefit a competitor.

Well written, comprehensive fraud reports can make fraud scenarios real by concretely demonstrating the actual value of the fraud prevention effort to enterprise management and the Board. They can also graphically help set the boundaries for the expectations of what management will expect the prevention function to do in the future if this, or similar scenarios, actually re-occur. The written presentation of the principal fraud or loss scenario treated in the report necessarily involves consideration of the vital controls in place to prevent its reoccurrence which then allows for the related presentation of a qualitative assessment of the present effectiveness of the controls themselves. A well written report thus helps everyone understand how all the control failures related to the fraud interacted and reinforced each other; it’s, therefore, only natural that the fraud examiner or analyst recommend that the report’s intelligence be channeled for use in the enterprise’s fraud and loss prevention program.

Strong fraud report writing has much in common with good story telling. A narrative is shaped explaining a sequence of events that, in this case, has led to an adverse outcome. Although sometimes industry or organization specific, the details of the specific fraud’s unfolding always contains elements of the unique and can sometimes be quite challenging for the examiner even to narrate. The narrator/examiner should especially strive to clearly identify the negative outcomes of the fraud for the organization for those outcomes can sometimes be many and related. Each outcome should be explicitly explicated and its impact clearly enumerated in non-technical language.

But to be most useful as a future fraud prevention tool the examiner’s report needs to make it clear that controls work as separate lines of defense, at times in a sequential way, and at other times interacting with each other to help prevent the re-occurrence of the adverse event. The report should attempt to demonstrate in plain language how this structure broke down in the current instance and demonstrate the implications for the enterprise’s future fraud prevention efforts. Often, the report might explain, how the correct operation of just one control may provide adequate protection or mitigation. If the controls operate independently of each other, as they often do, the combined probability of all of them failing simultaneously tends to be significantly lower than the probability of failure of any one of them. These are the kinds of realities with the power to significantly and positively shape the fraud prevention program for the better and, hence, should never be buried in individual reports but used collectively, across reports, to form a true combined resource for the management of the prevention program.

The final report should talk about the likelihood of the principal scenario being repeated given the present state of preventative controls; this is often best-estimated during discussions with client management, if appropriate. What client management will truly be interested in is the probability of recurrence, but the question is actually better framed in terms of the likelihood over a long (extended) period of time. This question is best answered by involved managers, in particular with the loss prevention manager. If the answer is that this particular fraud risk might materialize again once every 10 years, the probability of its annual occurrence is a sobering 10 percent.

As with frequency estimation, to be of most on-going help in guiding the fraud prevention program, individual fraud reports should attempt to estimate the severity of each scenario’s occurrence. Is it the worst case loss, or the most likely or median loss? In some cases, the absolute worst case may not be knowable, or may mean something as disastrous as the end-of-game for the organization. Any descriptive fraud scenario presented in a fraud report should cover the range of identified losses associated with the case at hand (including any collateral losses the business is likely to face). Documented control failures should always be clearly associated with the losses. Under broad categories, such as process and workflow errors, information leakage events, business continuity events and external attacks, there might have to be a number of developed, narrative scenarios to address the full complexity of the individual case.

Fraud reports, especially for large organizations for which the risk of fraud must always remain a constant preoccupation, can be used to extend and refine fraud prevention programs. Using the documented results of the fraud reporting process, report data can be converted to estimates of losses at different confidence intervals and fed to the fraud prevention program’s estimated distributions for frequency and severity. The bottom line is that organizations of all sizes shouldn’t just shelve their fraud reports but use them as vital input tools to build and maintain the ongoing process of fraud risk assessment for ultimate inclusion in the enterprise’s loss prevention and fraud prevention programs.

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.

When You Assume

by Rumbi Petrozzello
2018 Vice President – Central Virginia ACFE Chapter

On November 8, 2007, in the small town of Constantine, Michigan, 11-year-old Jodi Parrack was reported missing. Residents from the surrounding region volunteered to search for the missing girl, including Ray McCann, a police reservist. During the search, Ray suggested to Jodi’s mother, Valerie, that they should search for Jodi in the local cemetery. Valerie and Ray did so and, tragically, found her daughter there; she had been murdered.

Almost immediately, Ray came under suspicion. His reaction to Jodi’s death appeared to some of the investigators to be suspicious and why had he suggested that he and Valerie go to the cemetery, of all places, to look for Jodi? Then, during their subsequent investigation, the police found Jodi’s DNA on Ray’s body; according to Ray this was because he had pulled Valerie away from Jodi when he and her mother discovered the child’s body.

For years, Ray was under suspicion. He was brought in for questioning by the police on multiple occasions, and his answers, as far as the police were concerned, were not particularly convincing. He claimed to have been in one place and the police said that there was proof that he was not there. Seven years after Jodi’s murder, Ray was arrested and charged with perjury, related to the answers he had originally given the police; this seems to have been a tactic the police employed to hold him while they continued to try to gather enough evidence to charge him with Jodi’s murder.

While Ray was being held and facing from two to twenty years behind bars, another girl was attacked; she fought back, escaped and led the police to another man, Daniel Furlong. It turned out that Furlong’s DNA had been found on Jodi’s body during the original investigation as well as Ray’s and yet, the police had persisted in focusing solely on Ray. It was also revealed that the authorities were not honest when they told Ray that they possessed evidence Ray was lying. All the police really had was a deeply held conviction that Ray was being deceptive, leading to their determination to somehow develop evidence to validate that feeling.

By the time Ray was released after spending 20 wasted months of his life behind bars, he had lost his job, his family and the trust of the community in which he lived and which he had hoped someday to serve.

As Fraud Examiners and/or Forensic Accountants, we are engaged to investigate alleged wrongdoing and to follow up on leads as we work to resolve often confusing and contradictory matters. As we seek evidence, interview people and try to figure out what happened and who did what, it can be all too easy to make the mistake of viewing a red flag as somehow constituting proof. If someone giggles when they’re telling you they know nothing; if a person taps her foot throughout an interview, or if someone is extremely helpful, none of those things in themselves means anything definitive in resolving the question as to whether or not they have done anything wrong, let alone illegal.

Professional skepticism is a CFE’s tendency not to believe or take anyone’s assertions at face value, a mental tendency to ask every assertion to “prove it” (with evidence). The inevitable occurrence of confusion, errors and deception in all situations involving actual or suspected fraud dictates this basic aspect of professional skepticism. Persuading a skeptical CFE or forensic accountant is not impossible, just somewhat more difficult than persuading a normal person in an everyday context. Our skepticism protects the Ray McCann’s of this world because it’s a manifestation of objectivity, holding no special concern for preconceived conclusions on any side of an issue. Skepticism is not an attitude of being cynical, hypercritical, or scornful. The properly skeptical investigator asks these questions (1) What do I need to know? (2) How well do I know it? (3) Does it make sense?

Professional skepticism should lead investigators to appropriate inquiry about every clue involving seeming wrong doing. Clues should lead to thinking about the evidence needed, wringing out all the implications from the evidence, then arriving at the most suitable and supportable explanation. Time pressure to complete an investigation is no excuse for failing to exercise professional skepticism and bias and prejudice are always unacceptable. Too many investigators (including auditors) have gotten themselves into trouble by accepting some respondent’s glib assertion and stopping too early in an investigation without seeking facts supportive of alternative explanations.

A red flag means only that further investigation is warranted; it definitely does not mean that the examiner should shut down all other avenues of investigation and it certainly does not mean that an attempt should ever be made to make the crime fit the person. In the sad case of Ray McCann, the police continued to pursue him to the exclusion of all others even though they had found someone else’s DNA on Jodi’s body. They never appeared to be even looking for any other suspect. Even when Daniel Furlong subsequently confessed to murdering Jodi, the local authorities still persisted in implying that Ray was somehow connected to the crime; in the face of all contradictory evidence, the police still stubbornly refused to let go of their original hypothesis.

As we pursue our work as forensic accountants and fraud examiners, we should be constantly reviewing our hypotheses and assessing our approaches.

• Are we trying to make evidence fit the facts as we initially suppose them to be?
• Are we ignoring evidence because it does not fit the story we’re trying to tell?
• Are we letting a particular person’s behavior cloud a more objective judgment of the totality of what’s going on?

Often, even after a person has been cleared of suspicion in a case, we hear parties involved in the investigation make statements along the lines of, “I just know they are good for something.” Fortunately, our practice is not founded on feelings and gut instincts; our practice, and profession, is one that relies on evidence. As you’re investigating a matter, keep in mind:

• Following your defined process and procedure throughout is paramount to investigative success. Even if someone or some aspect of a case looks totally transparent within the context of the investigation, be thorough and follow your evidence all the way through.

• If your findings do not support your original premise, don’t try to force things. Step back and ask yourself why this is the case. Ask yourself if you need to reconsider your foundational hypothesis.

• Beware of confirmation bias – that is be careful that you are not looking only for data that reinforces the conclusion(s) that you have already reached (and, in so doing, ignoring anything that might prove contradictory).

• Even if your team is determined to work the assignment in a particular direction, make sure you speak up and let them know about any reservations you might have. You may not have the popular position, but you may end up expressing the critical position if it turns out that there is other evidence in light of which the conclusions the team has made need to be adjusted.

In summary, when you feel it in your gut and you are absolutely sure that you are right about a hypothesis, it’s very difficult to look beyond your conviction and to see or even consider other options. It’s vital that you do so since, as the ACFE has pointed out so many times, there is a hefty price to be paid professionally for ignoring evidence which eventually proves to be critical simply because it appears not to corroborate your case. Due professional care requires a disposition to question all material assertions made by all respondents involved in the case whether oral or written. This attitude must be balanced with an open mind about the integrity of all concerned. We CFEs should neither blindly assume that everyone is dishonest nor thoughtlessly assume that those involved in our investigations are not ethically challenged. The key lies in the examiner’s attitude toward gathering the evidence necessary to reach reasonable and supportable investigative decisions.

Write & Wrong

It’s an adage in the auditing world that examination results that can’t be effectively communicated might as well not exist.  Unlike a financial statement audit report, the CFE’s final report presents a unique challenge because there is no standardized format. Our Chapter receives more general inquiries from new practitioners about the form and content of final examination reports than about almost any other topic.

Each fraud investigation report is different in structure and content, depending on the nature and results of the assignment and the information that needs to be communicated, as well as to whom the results are being directed. To be effective, therefore, the report must communicate the findings in an accurate and concise form. Corporate counsel, law enforcement, juries, an employing attorney and/or the audit committee and management of the victimized organization must all be able to delineate and understand the factual aspects of the fraud as well as the related risks and control deficiencies discovered so that appropriate actions can be taken timely. Thus, the choice of words used and the tone of the CFE’s final report are as important as the information presented within it. To help ensure their reports are persuasive and bring positive results, CFEs should strive to keep them specific, meaningful, actionable, results oriented, and timely.

Because the goal of the final report is to ensure that the user can interpret the results of the investigation or analysis with accuracy and according to the intentions of the fraud examiner or forensic accountant, the report’s tone and structure are paramount. The report should begin by aligning issues and recommendations with applicable ACFE and with any other applicable professional standards and end with results that are clearly written and timely presented. To ensure quality and accuracy, there are some basic guidelines or ground rules that authorities recommend should be considered when putting together a final report that adds value.

The CFE should consider carefully what specifically to communicate in the report, including the conditions, cause, effect, and “why” of each of the significant fraud related facts uncovered.  Fraud investigators should always identify and address issues in a specific context rather than in broad or general terms. For example, stating that the fraud resulted from weaknesses in the collection and processing of vendor payment receipts is too broad. The report should identify the exact circumstances and the related control issues and risk factors identified, the nature of the findings, an analysis of the specific actions constituting the fraud and some discussion (if the CFE has been requested to do so) of possible corrective actions that might be taken.

To force the writing toward more specificity, each paragraph of the report should express only one finding, with major points enumerated, or bulleted, and parallel structure should be used for each itemized statement of a listing of items. Further, the most important findings should be listed in the first sentence of a paragraph. Once findings are delineated, the explanatory narration of facts aligned to each finding should be presented. Being specific means leaving nothing to the
user’s interpretation beyond that which is intended by the writer.  Another way to achieve specificity is to align the writing of the report to an existing control framework like the Committee of Sponsoring Organizations of the Treadway Commission’s (COSO’s) internal control or risk management frameworks. When issues are aligned with existing standards or to a framework, it can be easier for the CFE to explain the weaknesses in the client’s control environment that made the fraud possible.

The question to be answered is: Can the client(s) readily tell what the issues are by reading the investigative report alone? If the answer is “no,” how will they satisfactorily address areas the client will eventually deem important in moving forward toward either remediation or possible prosecution? This aspect of the writing process requires the practitioner to, first, identify to whom the final report is specifically directed and, second, determine what is to be communicated that will add value for the client. For example, the report may a communication to an employing attorney, to corporate counsel, to the client’s management or audit committee or to all three. What are their expectations? Is the report the result of a routine investigation requested by client management of possible accounts payable fraud or a special investigation to address a suspected, specifically identified fraud? The answer to these and related questions will help determine the appropriate technical level and tone for the report.

When there are different readers of the report, the process necessarily becomes more complex under the necessity to meet the expectations, understandings and eventual usages of all the parties. Finding the right words to address the identified fraud related facts in a positive tone, especially when client conditions surrounding the fraud are sometimes sensitive or at least not favorable, is crucial to making the report meaningful as well as persuasive. The investigative findings must be clear and logical. If the reported results are understood and meaningful actions that add value to the position of the various users are taken because of the findings, then the purpose and meaning of the CFE’s report (and work) will be realized.

What about investigative situations in which the CFE or forensic accountant is asked to move beyond a straight-forward presentation of the facts and, as an expert on fraud and on fraud prevention, make recommendations as to corrective actions that the client might take to forestall the future commission of frauds similar to those dealt with in the final report? In such cases (which are quite common, especially with larger clients), the final report should strive to demonstrate to the extent possible the capacity of the entity to implement the recommendations the CFE has included in the report and still maintain an acceptable level of operation.  To this end, the requested recommended actions should be written in a way that conveys to management that implementing the recommendations will strengthen the organization’s overall fraud prevention capability. The writing, as well as the complexity of the corrective action, should position the client organization to implement recommendations to strengthen fraud prevention. The report should begin with the most critical issue and progress to the least important and move from the easiest recommended corrective steps to the most difficult, or to the sequence of steps to implement a recommendation. The cost to correct the fraud vulnerability should be
apparent and easily determined in the written report. Additionally, the report should provide management with a rubric to evaluate the extent to which a deficiency is corrected (e.g., minimally corrected, fully corrected). Such a guide can be used to gauge the fraud prevention related decisions of management and serve as a basis for future fraud risk assessments.

Developing the CFE’s final report is a process that involves four stages: outlining, drafting, revising, and editing. In the outlining stage, the practitioner should gather and organize the information so that, when converted to a report, it is easy for the reader to follow. This entails reviewing the working papers and making a list of the fraud related facts to be addressed and of their related chronologies. These should be discussed with the investigative team (if any) and the
client attorney, if necessary, to ensure that there is a clear understanding of the underlying facts of the case. Any further work or research should be completed at this stage. This process may be simple or complicated, depending on the extent of the investigation, the unit or operation that is under examination, and the number of fraud related facts that must be addressed.

Once all information has been gathered, the next stage is writing the draft of the report. In completing the draft, concise and coherent statements with sufficient detail should enable the reader to understand the chronology and related facts of the fraud, the fraud’s impact on operations, and the proposed corrective actions (if requested by the client). After completing the draft, revisions may be necessary to make sure that the evidence supports the results and is written in a specific context.

The final stage involves proofreading and editing for correct grammar, sentence structure, and word usage to ensure that the facts and issues related to the fraud are effectively and completely presented and that the report is coherent. Reviewers should be used at this stage to give constructive feedback. Several iterations may be necessary before a final report is completed.

In summary, the CFE’s final report should be designed to add value and to guide the client organization’s subsequent steps to a satisfactory overall fraud response and conclusion. If the CFE’s report is deficient in communicating results, critical follow-on steps requiring immediate action may be skipped or ignored. This can be costly for any company in lost opportunities for loss recoveries, botched prosecutions and damaged reputation.

First Steps to Prosecution

A recent study sponsored by the financial trade press indicated some haziness among assurance professionals generally about the precise mechanism(s) underlying the process by which the authorities make the initial decision to prosecute or not to prosecute alleged financial statement fraud.

In the U.S. federal system, a criminal investigation of fraudulent financial reporting can originate in all sorts of ways. An investigation may be initiated because of a whistleblower, an anonymous tip, information supplied by a conscientious or guilt-ridden employee, or facts discovered during a routine annual audit of the company’s financial statements. In addition, the company’s public disclosure of financial misstatements may itself lead to the commencement of a criminal investigation. However initially initiated, the decision to start a criminal investigation is entirely within the discretion of the United States Attorney in each federal district.

For the prosecutor, the decision whether to open an investigation can be difficult. The main reason is the need for the prosecutor to establish criminal intent, that is, that the perpetrator not only got the accounting wrong but did so willfully. Often, bad accounting will be the result of judgment calls, which can be defended as exactly that, executive determinations or judgement calls that, while easy to second guess with the benefit of hindsight, were made in good faith at the time. Thus, a prosecutor evaluating the viability of a criminal prosecution will be looking for evidence of conduct so egregious that the perpetrator must have known it was wrong. This is not to suggest that evidence of a wrongful intent is the only consideration. A prosecutor’s exercise of his or her prosecutorial discretion may consider all kinds of factors in deciding whether criminal inquiry is warranted. Those factors may include the magnitude and nature of the accounting misstatements, whether individuals personally benefited from the misstatements or acted pursuant to the directive of a superior, whether documents were fabricated or destroyed, the probable deterrent or rehabilitative effect of prosecution, and the likelihood of success at trial. The availability of governmental resources may also be a factor.

Where the putative defendant is a corporation, partnership, or other business organization, a more settled set of factors come into play:

–The nature and seriousness of the offense, including the risk of harm to the public, and applicable policies and priorities, if any, governing the prosecution of corporations for certain categories of crime;
–The pervasiveness of wrongdoing within the corporation, including the complicity in, or the condoning of, the wrongdoing by corporate management;
–The corporation’s history of similar misconduct, including prior criminal, civil, and regulatory enforcement actions against it;
–The corporation’s timely and voluntary disclosure of wrong-doing and its willingness to cooperate in the investigation of its agents;
–The existence and effectiveness of the corporation’s preexisting compliance program;
–The corporation’s remedial actions, including any efforts to implement an effective corporate compliance program or to improve an existing one, to replace responsible management, to discipline or terminate wrongdoers, to pay restitution, and to cooperate with the relevant government agencies;
–Collateral consequences, including whether there is disproportionate harm to shareholders, pension holders, employees, and others not proven personally culpable, as well as the impact on the public arising from the prosecution;
–The adequacy of the prosecution of individuals responsible for the corporation’s malfeasance;
–The adequacy of remedies such as civil or regulatory enforcement actions.

However, a prosecutor gets there, once s/he determines to commence a criminal investigation, there is no doubt that those who are its targets will quickly come to view it as a priority over everything else. The government’s powers to investigate are broad, and, once a determination to go forward is made, the full resources of the government, including the FBI, can be brought to bear. The criminal sentences resulting from a successful prosecution can be severe if not excessive, particularly considering the enhanced criminal sentences put in place by Sarbanes-Oxley.  The ACFE reports that one midlevel executive at a company who elected to proceed to trial was convicted and received a prison sentence of 24 years. The fact that the sentence was subsequently set aside on appeal does little to mitigate the concern that such a sentence could be imposed upon a first-time, nonviolent offender whose transgression was a failure to apply generally accepted accounting principles.

Typically, a company learns that it is involved in a criminal investigation when it receives a grand jury subpoena, in most instances a subpoena duces tecum, compelling the company or its employees to furnish documents to the grand jury. In an investigation of fraudulent financial reporting, such a subpoena for documents may encompass all the files underlying the company’s publicly disseminated financial information, including the records underlying the transactions at issue and related emails.

For a CFE’s client company counsel and for the company’s executives generally, the need to respond to the subpoena presents both an opportunity and a dilemma. The opportunity stems from the company’s ability, in responding to the subpoena, to learn about the investigation, an education process that will be critical to a successful criminal defense. The dilemma stems from the need to assess the extent to which active and complete cooperation should be pledged to the prosecutor at the outset. The formulation of a response to a criminal subpoena, therefore, constitutes a critical point in the investigatory process. Those involved are thereby placed in the position of needing to make important decisions at an early stage that can have lasting and significant effects.  The CFE can support them in getting through this process.

Once an initial review of the subpoena and its underlying substance is complete, one of the first steps in formulating a response is often for company counsel to make a phone call to the prosecutor to make appropriate introductions and, to the extent possible, to seek background information regarding the investigation. In this initial contact, the prosecutor will be understandably guarded. Nonetheless, some useful information will frequently be shared. A general impression may be gained about the scope and focus of the investigation and the timing of additional subpoenas and testimony. Thereafter, it is not unusual for an initial meeting to be arranged to discuss in greater detail the company’s response. One benefit of such a meeting is that some level of additional information may be forthcoming.

From the outset, company counsel will be undertaking a process that will be ongoing throughout the criminal proceedings: learning as much as possible about the prosecutor’s case. The reason is that, unlike a civil case, in which broad principles of discovery enable the defendants to learn the details of the adversary’s evidence, the procedural rules of a criminal investigation result in much greater secrecy. Less formal methods of learning the details of the prosecutor’s case, therefore, are critical. In these initial contacts, the establishment of a sound foundation for the company’s dealings with the prosecutor is an important aspect of the investigation. To state it simply, CFE’s should always support that those dealings be premised on a foundation of candor.

Although it may be appropriate at various stages to decline to discuss sensitive matters, counsel should avoid making a factual statement on any subject about which it may be incompletely or inaccurately informed. This admonition applies to subjects such as the existence and location of files, the burden of producing documents, and the availability of witnesses. It also applies to more substantive matters bearing on the guilt or innocence of parties. CFE’s should, again, counsel their clients that a relationship with the prosecutor based on trust and confidence is key.

The judgment regarding the extent of cooperation with the prosecutor can be a tough one. Unlike in a civil proceeding, where cooperation with regulatory authorities (such as the SEC) is generally the preferred approach, the decision to cooperate with the government in a criminal investigation may be much more difficult, insofar as a subsequent effort to oppose the government (should such a change of approach be necessary) would be impeded by the loss of a significant tactical advantage, the loss of surprise. In criminal cases, the government is not afforded the same broad rights of discovery available in civil proceedings. It is entirely possible for a prosecutor to have no significant knowledge of the defense position until after the start of a trial. On the other hand, the privileges available to a corporation are limited. There is, most importantly, no Fifth Amendment privilege against self-incrimination for companies.  Furthermore, almost any kind of evidence, even evidence that would be inadmissible at trial, except for illegal wiretaps or privileged material, can be considered by a grand jury. Therefore, the company’s ability to oppose a grand jury investigation is limited, and the prosecutor may even consider a company’s extensive zeal in opposition to constitute obstruction of justice. Moreover, the prosecutor’s ultimate decision about indictment of the company may be affected by the extent of the company’s cooperation. And corporate management may wish to demonstrate cooperation as a matter of policy or public relations.

One issue with which a company will need to wrestle is whether it is appropriate for a public company or its executives to do anything other than cooperate with the government. On this issue, it is useful for executives to appreciate that the U.S. system of justice affords those being investigated certain fundamental rights, and it is not unpatriotic to take advantage of them. As to individuals, one of the most basic of these rights is the Fifth Amendment privilege against self-incrimination. Insofar as, in fraud cases, guilt can be established through circumstantial evidence, executives need to keep in mind that it demonstrates no lack of civic virtue to take full advantage of constitutional protections designed to protect the innocent.

A challenge is that many of these judgments regarding cooperation must be made at the outset when the company’s information is limited. Often the best approach, at least as a threshold matter, will be one of courteous professionalism, meaning respect for one’s adversary and reasonable accommodation pending more informed judgments down the road. Premature expressions of complete cooperation are best avoided as a subsequent change in approach can give rise to governmental frustration and anger.

Following the initial steps of the grand jury subpoena and the preliminary contact with the prosecutor, CFE’s are uniquely positioned to assist corporate counsel and management in the remaining stages of the criminal investigation of a financial crime:

–Production of documents;
–Grand jury testimony;
–Plea negotiations (if necessary);
–Trial (if necessary).