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Make your suspected fraud referrals stand out to law enforcement

How can you ensure your suspected fraud referral will grab the attention of law enforcement?

That’s a challenge many insurance fraud investigators face, especially when trying to get law enforcement to read their fraud referrals over the dozens of others they receive.

In my 18 years of experience investigating medical and provider fraud – resulting in several successful law enforcement cases countrywide – I’ve found that it’s not only possible to make your referrals stand out, but it’s actually quite easy as well. Let me show you how.

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A simple formula that grabs attention

There is a longstanding advertising strategy referred to as the AIDA formula. AIDA is an acronym for attention, interest, desire, and action. Whether you’re writing an ad to sell a bar of soap or writing a suspected fraud referral, the mechanics of the AIDA formula are the same.

First, you write in a way that the first line the reader sees grabs their attention. Successfully grabbing the reader’s attention piques their interest, which leads to a desire to read more and ultimately to take some form of action.

Here’s an example. Let’s say you’re a MedSentry® client. You use the tool to discover providers who are generating questionable bills in your book of business, as well as the specific issues in those bills. You then take the MedSentry analysis to the next level by operationalizing the findings and conducting a full investigation.

Your investigation involves a background on the provider, a study of the provider’s billing and reporting, and interviews with patients. Ultimately, you develop supporting evidence that the subject provider has billed your company $125,000 in services not rendered.

When drafting your suspected fraud referral for law enforcement, the best way to grab their attention is to open with the ending.

Rather than starting with the chain of events that provoked SIU involvement and then moving on to where the story finally ends with your evidence discovery, instead, open with your finding that Dr. Doe billed $125,000 worth of services not rendered.

By opening with the ending, you grab the reader’s attention right away.

Drive interest with evidence to support referrals

Now that you have their attention, immediately follow with a brief representation of the evidence to support the allegations. This heightens the law enforcement representative’s interest and further provokes their desire to read more. Lastly, only at the end, articulate the chain of events that led to your investigative involvement and evidentiary discoveries.

Finally, the reader will decide what action to take, such as calling you or sending you a letter informing you that they are opening an investigation and requesting or subpoenaing your claim files and supporting documentation and evidence.

Getting the attention your case deserves

Let’s look at some examples of how opening lines for your suspected fraud referrals might read:

  • “Dr. Doe, M.D. admitted to billing $125k in treatment services he never actually rendered.”
  • “Dr. Doe, M.D. billed $15k in treatment to patient Emily Jones during the time patient Jones confirmed she was away on vacation and received no treatment.”
  • “Dr. Doe, M.D. routinely funnels patients for unnecessary treatment to XYZ Physical Therapy where he holds an undisclosed financial interest.”
  • “10 interviewed patients confirmed only seeing Dr. Doe, M.D. twice a week, yet the doctor routinely submitted treatment billings on all 10 patients for four times a week.”

Once you embrace this technique, some opening lines may be clear and easy to write. However, depending on the circumstances of your case, you may need to work on a few different opening line iterations for your suspect fraud referral. Share a few different iterations with colleagues and ask them which grabbed their attention the most. This process is similar to what advertising agencies do when using focus groups.

Whether your journey began with MedSentry, an adjuster referral, industry shared intelligence, or another source, using this tried-and-true method of focusing on the outcome of your case and opening your suspected fraud referrals with the ending should help separate your referrals from others in the herd and help garner the attention from law enforcement you desire and that your hard work deserves.


Bo Barber, CFE

Bo Barber, CFE, is director of investigative analysis for Verisk’s anti-fraud solutions group. For more information on how Verisk can help your organization detect medical provider fraud, contact Bo.Barber@verisk.com.


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