KPI Oklahoma

How a Private Investigator in OKC Successfully Investigates Medicare and Medicaid Fraud

Investigates Medicare and Medicaid Fraud

Medicare and Medicaid fraud are the prevalent issues private investigators in OKC come across in the Oklahoma healthcare system. There has been a surging rise in this act, resulting in higher healthcare costs, unjust use of taxpayers’ money, fewer incentives, reduced quality treatment, etc.

This illegal act is aimed toward benefiting unjust high payouts from these government-funded healthcare programs and can take various forms.

Some of the prevalent forms a private investigator in Oklahoma City may come across includes:

  • Phantom billing or Upcoding — This is when a health provider includes service codes for services that were not provided in a patient’s medical bill. It is one of the most prominent Medicare and Medicaid frauds committed by medical professionals.
  • Ping-ponging — This is another healthcare fraud a private investigator OKC can come across. It involves medical professionals performing unnecessary tests for patients to pad up their medical bills.

Ping-pong is another fraud type that unsuspecting patients become victims of due to their lack of medical knowledge. It could keep going on for a long time without the intervention of a private detective.

  • Unbundling — This Medicare/Medicaid fraud is a trick that involves charging per unit for services that are usually charged together.
  • Patient abuse or mistreatment — Abuse and mistreatment can come in various forms, and whichever form it comes, it can be punishable by the law if it’s established. While this isn’t fraud, it is another punishable Medicare/Medicaid-related crime.
  • Ineligibility Fraud — Patients or non-healthcare providers mostly commit this kind of fraud. Some patients or individuals always make false claims to receive benefits they’re not eligible for. This is always achieved through deception, false finance declaration, or manipulation.
  • Identity theft — This type of fraud occurs when an individual receives services by impersonating someone eligible to receive such service.

Most private investigators in Norman, Oklahoma, find any of these to be the case during their Medicare/Medicaid investigation. Private detectives have identified medical professionals, patients, healthcare facilities, and impersonators as prominent perpetrators of this fraud.

Most private investigator agencies in Oklahoma City ensure their private investigators are vast in the law provisions for health care fraud.

Hence, you can trust private investigator agencies like Keefe Private Investigators (KPI) for satisfactory Oklahoma Statewide Private Investigation on Medicare and Medicaid fraud.

Since these types of healthcare frauds are rampant, Oklahoma Judicial Process Servers (OJPS) and other private investigator agencies in OKC have a streamlined process of investigating related cases and getting results.

Below, we look into these processes and how Oklahoma private investigators carry them out.

Steps for Private Investigator Oklahoma to Successfully Investigate Medicare/Medicaid Fraud in Oklahoma City

Private investigators in Edmond, Oklahoma, and other private investigators in OKC have due processes for approaching each case. Medicare and Medicaid fraud is no exception.

These processes include:

  • Identification of Fraud Type

As mentioned earlier, Medicare and Medicaid fraud take various forms. A private investigator in Oklahoma must first identify the type of fraud committed before knowing the best approach to go against the possible offenders.

One of the best methods private investigators (PIs) employ to ascertain this is interview/interrogation. Information gathered from this approach gives solid clues and leads to the case.

Another approach that works is liaising with the state’s Program Integrity section or other body that does the same thing. The available information can give a private investigator OKC insights into the case.

  • Gathering of Facts and Evidence

After knowing the type of fraud being committed, the next step is to expose the fraud and convict the perpetrators. However, you can’t achieve this without enough facts and evidence.

Thus, a private investigator in Oklahoma City must take this step to ensure the case is seen to a reasonable conclusion. There are two potent approaches most PI in OKC utilizes to get results, which are:

  • Surveillance — This approach works when an individual files false claims for reimbursement. Most times, these individuals are always claiming to have received treatment for some severe accident or illness.

Effective surveillance can help get audio and visual evidence to prove otherwise. It is a suitable technique to approach workers’ compensation situations, insurance claims, and other related health frauds.

Surveillance has always been the primary investigation technique for private detectives, and lots of mysteries can be unraveled by doing it effectively.

  • Database Review — A lot of information is obtained from excellent database reviews. There’s always something to find, from patients declaring false financial information to health provider upcoding, ping-ponging, and unbundling.

One of the efficient ways private investigators in Oklahoma City use for investigating Medicare and Medicaid fraud is by leveraging the CLEAR database software tool.

The Citizen Law Enforcement Analysis and Reporting (CLEAR) software allow private detectives to access databases easily behind their desks and derive valuable information in less time.

Derived information is always critical to uncovering major fraud in the health sector. Top detectives in other states have successfully used the tool, and it’s been adopted efficiently by private investigator agencies in Oklahoma.

  • Background Checks — This is another practical investigative step to uncover Medicare and Medicaid fraud. Background checks reveal details about an individual’s past crime and claim records and other necessary information.

It could give the PI an insight into whether a healthcare provider is living above his means and other provided information that may not add up about the individual.

  • Information Verification

After a private investigator in Oklahoma must have gathered enough facts and evidence via any of the available techniques, the next thing is to ensure they are accurate and valid.

The accuracy and validity of the information ensure that a potential offender has no hiding place, and the available evidence is concrete enough to convict such a person.

A private detective would use available means to verify the information at his disposal before presenting it to the appropriate body to ensure the law takes its cause.


Medicare and Medicaid fraud are on the rise, and we can’t downplay the need for effective investigation. Private investigators in OKC deploy effective methods to ensure these investigations yield results and perpetrators don’t go unpunished.

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