2016 Fraud Trends in the Healthcare Industry

By Matthew O. McDonald, CPA/CFF, CFE, Partner

2016 Fraud Trends in the Healthcare Industry

By Matthew O. McDonald, CPA/CFF, CFE, Partner

The Association of Certified Fraud Examiners recently published its biennial “Report to the Nations on Occupational Fraud and Abuse”.  One of the stated goals of the report is to provide awareness of fraud risk an organization may have to deal with.  The 2016 global fraud study highlights the current trends for those with an interest in reducing the threat of occupational fraud.

Highlights from those participating in 2016 report include the following:

  • Estimated loses for a typical organization was 5% of revenues in a given year
  • An average loss per case was $2.7 million, with total loses on all cases exceeding $6.3 billion (with a median loss of $150,000, and 23.2% of losses exceeding $1 million)
  • Asset misappropriation occurred in over 83% of the cases
  • Financial statement fraud occurred in less than 10% of the cases
  • Corruption occurred in approximately 35% of the cases
  • The medium time duration for a fraud was 18 months
  • Perpetrators in over 94% of the cases took steps to conceal the fraud, with the most common methods were creating and altering physical documents
  • Tips was the most common detection method (approximately 39% of the cases)
  • The manufacturing industry was one of the most representative sectors of cases reported (along with banking and financial services and government and public administration)
  • The perpetrator’s level of authority was strongly correlated with the size of the fraud
  • The more individuals involved, the higher the losses tended to be.
    • Single perpetrator – $85,000 loss
    • Two perpetrators – $150,000 loss
    • Three perpetrators – $220,000 loss
    • Four perpetrators – $294,000 loss
    • Five or greater – $633,000 loss
  • 7% of victim organizations decided not to refer their fraud cases to law enforcement

For healthcare, number of cases and median losses are as follows:

Industry Cases % of Cases Median Loss
Healthcare 144 6.6% $120,000

The frequency of the schemes used in perpetuating the frauds by industry are as follows:

Scheme Healthcare
Billing 31.3%
Cash Larceny 9.7%
Cash on Hand 11.1%
Check Tampering 14.6%
Corruption 30.6%
Expense Reimbursement 20.1%
Financial Statement Fraud 13.2%
Non-Cash 13.2%
Payroll 9.7%
Register Disbursements 2.1%
Skimming 12.5%

(Note:  Yes, these do not add to 100%.  More than one scheme may have been identified in particular cases.)

Trends in the implementation of anti-fraud controls worldwide include establishing hotlines, conducting fraud training for employees or managers/executives, establishing of anti-fraud policies and codes of conduct, strengthening management review, and performing surprise audits.

The complete 2016 Report covers more than 90 pages of information and the above is just a snapshot of facts gleaned from its detail.  You can get more information and view the entire report at www.acfe.com/rttn2016.  Should you have specific questions pertaining to your organization and anti-fraud measures, please contact your Keiter service provider or 804.747.0000 | Contact us.

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About the Author

Matthew O. McDonald

Matthew O. McDonald, CPA/CFF, CFE, Partner

Matt has over 20 years in public accounting providing audit, tax, and consulting services for HUD financed housing, VHDA financed housing and construction, not-for-profit organizations, construction, retail, and manufacturing clients. Matt is a member of the Firm’s Not-for-Profit team and Real Estate & Construction industry team.

Matt supervises the work necessary to form the basis of expert witness testimony for Keiter’s Valuation and Forensic Services group and has qualified and testified as an expert witness in the Commonwealth of Virginia. Learn more about Matt.

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The information contained within this article is provided for informational purposes only and is current as of the date published. Online readers are advised not to act upon this information without seeking the service of a professional accountant, as this article is not a substitute for obtaining accounting, tax, or financial advice from a professional accountant.


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