Integrity, Ethics and Discipline are Foundation of CFE's Career

One would think that Matthew Lynch, CFE, Director of Special Investigations Unit for Healthfirst, was raised to be a fraud fighter. “I’m the product of Catholic school and Military College discipline and education — with emphasis on the discipline.”

May 2016

ACFE Member Profile
Matthew Lynch
Director of Special Investigations Unit
Healthfirst

One would think that Matthew Lynch, CFE, Director of Special Investigations Unit for Healthfirst, was raised to be a fraud fighter. “I’m the product of Catholic school and Military College discipline and education — with emphasis on the discipline,” said Lynch. “The Citadel taught me the importance of integrity, ethics and discipline — lessons that were reinforced by my Marine Corps training, which have been the foundation of my career.” It is also not surprising that he is a strong believer in the importance of a collaborative fraud-fighting community. “There is great value in the perspective of others,” says Lynch. Under his direction his team ensures due diligence through teamwork and discussions of on-going investigations. “Learning to listen to others before making conclusions is critical.”

How did you transition from the Marine Corps into the investigations field?

As a cadet at The Citadel, I was in the Marine Corps scholarship program. The combination of a shoulder injury and the end of the Vietnam War ended my military career but not before multiple attempts after graduation (on my part) to change their mind! This prompted a change in direction for me and led me to follow the steps of other family members to go into law enforcement.

My investigative training took a long and winding road: an unusual blend of private and public investigative experience crossing multiple industries and countries. I have been a Deputy Sheriff in Charleston and Columbia, South Carolina; an Ombudsman Investigator handling cases of abuse, neglect and financial exploitation of the elderly; a Medicare anti-fraud investigator; a lead special audit investigator for a Fortune 100 global corporation conducting international internal, financial and FCPA investigations; and a Director of a Special Investigations Unit (SIU).

What is a challenging aspect of investigations within the health care insurance industry?

Health care fraud investigators have the added challenge of having to understand the taxonomy and language associated with these frauds and their interactions. On top of being a skilled fraud investigator, they need to be part nurse, part claims specialist and part financial analyst. All of which is complicated by varying regulations governing Medicare, Medicaid and commercial lines of business.

How does your corporate investigations unit operate?

Our SIU functions under “corporate legal” and has four separate investigative components: Marketing Incidents Investigations involving marketing and sales representatives; Healthcare Fraud, Waste and Abuse (FWA) Investigations of member complaints; Healthcare FWA Proactive Data Analytic Investigations of providers, vendors, suppliers; and Internal/Corporate Investigations in support of Legal, Human Resources and Compliance. While my investigators and fraud examiners have specific investigative assignments, the majority are cross-functional.

How do you think the CFE credential has assisted your professional career as an investigator?

The CFE credential brought a significant level of respect for both the expectations of performance, as well as for my professional insight and opinion. It opens avenues of opportunity across different industries. Because of this, I encourage and support my staff in pursuing their certification — in spite of the fact that it makes them highly marketable to other companies. I’m very proud that 40 percent of them have their CFE.

What are the important investigative skills that you have learned throughout your career and as a CFE?

The most important thing I’ve learned is that there are multiple ways to interpret the facts and it’s best to get the opinion of other investigators. For that reason, all of our cases start with an initial case plan that is a collaborative effort. Interviews are conducted by two investigators and final investigative reports have dual review to ensure thorough due diligence occurred. As a unit, we meet weekly for “SIU Rounds” to discuss new and ongoing investigations. This exposes staff to investigations outside their normal sphere and elicits input from a different perspective. Learning to listen to others before making conclusions is critical.

How do you stay up to date on the latest fraud schemes that people try and perpetrate at your establishments?

There is a plethora of information available and one person can’t stay on top of it. I rely on my staff to monitor certain sources and summarize as needed. These sources include the Association of Certified Fraud Examiners (ACFE), National Health Care Anti-fraud Association (NHCAA), U.S. Department of Justice (DOJ), Office of the Medicaid Inspector General (OMIG) and Attorney General (AG) websites; as well social media sites like LinkedIn and Twitter. Additionally, we participate in federal, state and private task forces, meetings and various associations’ trainings.

What do you hope to personally pass on to the next generation of fraud fighters?

Look, listen and learn:

• Look for ways to proactively identify fraud and to expand your Fraud, Waste and Abuse (FWA) footprint — risk management offers a far better return-on-investment.
• Listen well, especially to those around you. There is great value in the perspectives of others.
• Learn that what you know is not enough.

The key motivators for fraud may not change, but the schemes are always morphing, as the resources to fight them are frequently changing.

What activities or hobbies do you like to do outside of work?

While family occupies a great part of my life outside of work, I also enjoy theater, ballet, travel and indulging my passion for painting.