Amtrak employee Rodolfo Rivera, 41, of Clayton, Delaware, pled guilty in federal court in New Jersey to one count of conspiracy to commit health care fraud.
Prosecutors allege that from January 2019 through June 2022, Rivera and other Amtrak employees agreed with certain health care providers to submit claims for services that were not provided or not medically necessary, in exchange for cash kickbacks.
The Amtrak health care plan paid more than $2 million in fraudulent claims associated with Rivera, his dependent, and other employees he recruited, and more than $11 million in total fraudulent claims tied to providers in the scheme.
Rivera received thousands of dollars in cash kickbacks from providers including an acupuncturist and a podiatrist, both of whom previously pled guilty to related offenses.
Source: https://www.justice.gov/usao-nj/pr/amtrak-employee-admits-participating-11-million-health-care-fraud-scheme
Commentary
The article source indicates employees were accused of working with external health care providers to fake medical claims against their employer's health plan in return for cash kickbacks, resulting in multi-million-dollar losses.
A key lesson is that executives must governance, controls, and oversight to make such schemes more difficult to introduce and easier to trace.
Such steps could include:
- Establishing strong health plan claims analytics to detect abnormal billing trends from providers, services, or employees.
- Regularly conducting audits between the health plan administrator, internal audit, and compliance to review high risk providers and repeat high value claims.
- Establishing transparent codes of conduct and conflict of interest policies that prevent employees from receiving any value from vendors or providers that have a link to company benefits.
- Having confidential reporting channels to allow employees to report suspected benefits fraud or strange relationships between coworkers and providers.
- Making sure that investigations are carried out through internal audit, legal, compliance, and, if applicable, law enforcement or inspector general offices if fraud is suspected.
- Offering ongoing training for managers and staff on identifying health care fraud signs and the penalties for engaging in benefit programs.
The final takeaway for leadership is that employee benefit plans can be a major fraud target and hence require the same level of control, scrutiny, and monitoring as is required for all financial assets.
