Clinic owner conceals $3.3 Million in Medicare fraud

Publisher
The Office of the Commonwealth Director of Public Prosecutions
Date published
October 2018

Relevant impacts: Financial impact, reputational impact, industry impact and business impact

A medical clinic owner defrauded the Commonwealth of more than $3.3 million by claiming rebates for services not given to over 5,870 different patients. He deleted the claims from the clinic's practice management software shortly after submitting them in order to avoid detection from employees and health practitioners of the clinic. The investigation was commenced when several members of the public made enquiries about their claim history for services they had neither sought nor received. The man pleaded guilty to 6 charges of fraud under the Criminal Code 1995 (Cth) and was sentenced to 6 years in prison.

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Related fraudster personas

The Concealer

The Concealer hides their actions from being seen or known about to dishonestly gain personal benefits.

The Deceiver

The Deceiver makes others believe something that is not true to dishonestly gain personal benefits.

Related countermeasures

Verify information

Verify any requests or claim information you receive with an independent and credible source.

Automatic notifications

Automatically notify clients or staff about high-risk events or transactions. This can alert them to potential fraud and avoid delays in investigating and responding to fraud.

Complaints handling

Allow clients, staff and third parties to lodge complaints about actions or decisions they disagree with. This may identify fraud or corruption as a cause for complaints, such as a failure to receive an expected payment.

Reconcile records

Reconcile records to make sure that 2 sets of records (usually the balances of 2 accounts) match. Reconciling records and accounts can detect if something is different from what is standard, normal, or expected, which may indicate fraud.

Audit logging

Audit logging is system-generated audit trails of staff, client or third-party interactions that help with fraud investigations.

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