""" Synthetic government fraud documents for all 3 tasks. All data is entirely fictional. Generated deterministically so graders are reproducible. """ from __future__ import annotations from typing import Any, Dict # --------------------------------------------------------------------------- # TASK 1 — Easy: Duplicate Medicare billing detection # --------------------------------------------------------------------------- TASK1_DOCUMENTS: Dict[str, Dict[str, Any]] = { "CLAIM-001": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-001", "preview": "Patient P4421, Procedure 99213, Date 2024-03-15, $185.00", "content": { "claim_id": "MC-2024-001", "patient_id": "P4421", "patient_name": "Robert Haines", "procedure_code": "99213", "procedure_desc": "Office visit – established patient, moderate complexity", "service_date": "2024-03-15", "billed_amount": 185.00, "provider_id": "PRV-8821", "provider_name": "MedCorp Associates LLC", "npi": "1234567890", "diagnosis_code": "Z00.00", "place_of_service": "11 - Office", "submitted_date": "2024-03-22", }, }, "CLAIM-002": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-002", "preview": "Patient P4421, Procedure 99213, Date 2024-03-15, $185.00", "content": { "claim_id": "MC-2024-002", "patient_id": "P4421", "patient_name": "Robert Haines", "procedure_code": "99213", "procedure_desc": "Office visit – established patient, moderate complexity", "service_date": "2024-03-15", "billed_amount": 185.00, "provider_id": "PRV-8821", "provider_name": "MedCorp Associates LLC", "npi": "1234567890", "diagnosis_code": "Z00.00", "place_of_service": "11 - Office", "submitted_date": "2024-03-28", "note": "Resubmission - original claim lost", }, }, "CLAIM-003": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-003", "preview": "Patient P8832, Procedure 93000, Date 2024-03-20, $320.00", "content": { "claim_id": "MC-2024-003", "patient_id": "P8832", "patient_name": "Linda Forsythe", "procedure_code": "93000", "procedure_desc": "Electrocardiogram, routine ECG with 12 leads", "service_date": "2024-03-20", "billed_amount": 320.00, "provider_id": "PRV-3342", "provider_name": "HeartCare Diagnostics Inc", "npi": "9876543210", "diagnosis_code": "I10", "place_of_service": "22 - Outpatient Hospital", "submitted_date": "2024-03-25", }, }, "CLAIM-004": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-004", "preview": "Patient P4421, Procedure 99213, Date 2024-03-16, $185.00", "content": { "claim_id": "MC-2024-004", "patient_id": "P4421", "patient_name": "Robert Haines", "procedure_code": "99213", "procedure_desc": "Office visit – established patient, moderate complexity", "service_date": "2024-03-16", "billed_amount": 185.00, "provider_id": "PRV-8821", "provider_name": "MedCorp Associates LLC", "npi": "1234567890", "diagnosis_code": "Z00.00", "place_of_service": "11 - Office", "submitted_date": "2024-03-30", "note": "Date corrected from original submission", }, }, "CLAIM-005": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-005", "preview": "Patient P2271, Procedure 99214, Date 2024-03-18, $265.00", "content": { "claim_id": "MC-2024-005", "patient_id": "P2271", "patient_name": "Marcus Webb", "procedure_code": "99214", "procedure_desc": "Office visit – established patient, moderate-high complexity", "service_date": "2024-03-18", "billed_amount": 265.00, "provider_id": "PRV-8821", "provider_name": "MedCorp Associates LLC", "npi": "1234567890", "diagnosis_code": "J06.9", "place_of_service": "11 - Office", "submitted_date": "2024-03-24", }, }, "CLAIM-006": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-006", "preview": "Patient P5519, Procedure 71046, Date 2024-03-22, $410.00", "content": { "claim_id": "MC-2024-006", "patient_id": "P5519", "patient_name": "Dorothy Callahan", "procedure_code": "71046", "procedure_desc": "X-ray, chest, 2 views", "service_date": "2024-03-22", "billed_amount": 410.00, "provider_id": "PRV-7710", "provider_name": "Radiology Partners Group", "npi": "1122334455", "diagnosis_code": "R05.9", "place_of_service": "22 - Outpatient Hospital", "submitted_date": "2024-03-26", }, }, "CLAIM-007": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-007", "preview": "Patient P9934, Procedure 99213, Date 2024-03-14, $185.00", "content": { "claim_id": "MC-2024-007", "patient_id": "P9934", "patient_name": "Albert Nguyen", "procedure_code": "99213", "procedure_desc": "Office visit – established patient, moderate complexity", "service_date": "2024-03-14", "billed_amount": 185.00, "provider_id": "PRV-8821", "provider_name": "MedCorp Associates LLC", "npi": "1234567890", "diagnosis_code": "M54.5", "place_of_service": "11 - Office", "submitted_date": "2024-03-20", }, }, "CLAIM-008": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-008", "preview": "Patient P3387, Procedure 80053, Date 2024-03-19, $95.00", "content": { "claim_id": "MC-2024-008", "patient_id": "P3387", "patient_name": "Sandra Kim", "procedure_code": "80053", "procedure_desc": "Comprehensive metabolic panel", "service_date": "2024-03-19", "billed_amount": 95.00, "provider_id": "PRV-4421", "provider_name": "LabFirst Diagnostics LLC", "npi": "5544332211", "diagnosis_code": "E11.9", "place_of_service": "81 - Independent Laboratory", "submitted_date": "2024-03-23", }, }, "CLAIM-009": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-009", "preview": "Patient P6612, Procedure 99215, Date 2024-03-21, $355.00", "content": { "claim_id": "MC-2024-009", "patient_id": "P6612", "patient_name": "Franklin Torres", "procedure_code": "99215", "procedure_desc": "Office visit – established patient, high complexity", "service_date": "2024-03-21", "billed_amount": 355.00, "provider_id": "PRV-9908", "provider_name": "Premier Health Associates", "npi": "6677889900", "diagnosis_code": "F32.1", "place_of_service": "11 - Office", "submitted_date": "2024-03-27", }, }, "CLAIM-010": { "doc_type": "medicare_claim", "title": "Medicare Claim #MC-2024-010", "preview": "Patient P1143, Procedure 90837, Date 2024-03-17, $175.00", "content": { "claim_id": "MC-2024-010", "patient_id": "P1143", "patient_name": "Helen Okafor", "procedure_code": "90837", "procedure_desc": "Psychotherapy, 60 minutes", "service_date": "2024-03-17", "billed_amount": 175.00, "provider_id": "PRV-2255", "provider_name": "Behavioral Health Partners", "npi": "3344556677", "diagnosis_code": "F41.1", "place_of_service": "11 - Office", "submitted_date": "2024-03-22", }, }, } TASK1_GROUND_TRUTH = { "exact_duplicates": [("CLAIM-001", "CLAIM-002")], "near_duplicates": [("CLAIM-001", "CLAIM-004")], "clean_claims": ["CLAIM-003", "CLAIM-005", "CLAIM-006", "CLAIM-007", "CLAIM-008", "CLAIM-009", "CLAIM-010"], } # --------------------------------------------------------------------------- # TASK 2 — Medium: Shell company ownership tracing # --------------------------------------------------------------------------- TASK2_DOCUMENTS: Dict[str, Dict[str, Any]] = { "CONTRACT-001": { "doc_type": "government_contract", "title": "Federal Construction Contract #FC-2023-0847", "preview": "FastBuild LLC awarded $2.3M for GSA facility renovation", "content": { "contract_id": "FC-2023-0847", "vendor_name": "FastBuild LLC", "vendor_ein": "47-3821044", "award_amount": 2_300_000.00, "award_date": "2023-08-12", "project": "GSA Region 4 Facility Renovation – Atlanta", "contracting_officer": "J. Williams", "contracting_officer_id": "CO-4421", "period_of_performance": "2023-09-01 to 2024-03-31", "solicitation_type": "Sole Source – 8(a) Program", "naics_code": "236220", }, }, "CONTRACT-002": { "doc_type": "government_contract", "title": "Federal IT Contract #IT-2023-1102", "preview": "FastBuild LLC awarded $890K for network infrastructure", "content": { "contract_id": "IT-2023-1102", "vendor_name": "FastBuild LLC", "vendor_ein": "47-3821044", "award_amount": 890_000.00, "award_date": "2023-11-03", "project": "DOT Regional Office Network Upgrade", "contracting_officer": "J. Williams", "contracting_officer_id": "CO-4421", "period_of_performance": "2023-12-01 to 2024-06-30", "solicitation_type": "Sole Source – 8(a) Program", "naics_code": "541512", "note": "Outside vendor's primary NAICS code", }, }, "VENDOR-REG-001": { "doc_type": "vendor_registration", "title": "SAM.gov Registration – FastBuild LLC", "preview": "FastBuild LLC, Delaware LLC, EIN 47-3821044", "content": { "legal_name": "FastBuild LLC", "dba": None, "entity_type": "Limited Liability Company", "state_of_incorporation": "Delaware", "ein": "47-3821044", "cage_code": "8FB21", "uei": "FBLLC2023US", "registered_agent": "National Registered Agents Inc", "principal_address": "1209 Orange Street, Wilmington, DE 19801", "primary_naics": "236220", "8a_certified": True, "8a_certifying_entity": "SBA Region 4", "annual_revenue_reported": 180_000, "employees_reported": 3, "founded": "2022-11-14", "note": "Annual revenue inconsistent with contract awards", }, }, "STATE-FILING-DE-001": { "doc_type": "state_corporate_filing", "title": "Delaware Division of Corporations – FastBuild LLC", "preview": "FastBuild LLC 100% owned by ConstructPro Inc", "content": { "entity_name": "FastBuild LLC", "file_number": "DE-7734821", "formation_date": "2022-11-14", "registered_agent": "National Registered Agents Inc", "members": [ { "name": "ConstructPro Inc", "ownership_pct": 100, "state": "Nevada", "ein": "88-4421033", } ], "manager": "ConstructPro Inc", "status": "Active", }, }, "STATE-FILING-NV-001": { "doc_type": "state_corporate_filing", "title": "Nevada Secretary of State – ConstructPro Inc", "preview": "ConstructPro Inc owned by R. Holden Family Trust", "content": { "entity_name": "ConstructPro Inc", "file_number": "NV-C20190044231", "formation_date": "2019-03-22", "registered_agent": "Nevada Corporate Services LLC", "officers": [ {"title": "President", "name": "Redacted per NV statute §78.150"}, {"title": "Secretary", "name": "Redacted per NV statute §78.150"}, ], "shareholders": [ { "name": "R. Holden Family Trust", "trust_state": "Delaware", "ownership_pct": 100, "trustee": "See trust documents", } ], "status": "Active", "note": "Nevada does not require disclosure of beneficial owners", }, }, "TRUST-DOC-001": { "doc_type": "trust_document", "title": "R. Holden Family Trust – Declaration of Trust", "preview": "Trustee: Raymond T. Holden. Beneficiaries include family members.", "content": { "trust_name": "R. Holden Family Trust", "trust_state": "Delaware", "trust_date": "2018-09-01", "trustee": "Raymond T. Holden", "trustee_address": "412 Magnolia Drive, Atlanta, GA 30301", "beneficiaries": [ {"name": "Raymond T. Holden", "relationship": "Grantor"}, {"name": "Patricia Holden-Williams", "relationship": "Spouse"}, {"name": "Derek Williams", "relationship": "Son-in-law"}, ], "assets": "All shares of ConstructPro Inc and affiliated entities", }, }, "GOV-EMPLOYEE-001": { "doc_type": "government_employee_record", "title": "Federal Employee Record – CO-4421", "preview": "Contracting Officer James Williams, GSA Region 4", "content": { "employee_id": "CO-4421", "name": "James Williams", "agency": "General Services Administration", "region": "Region 4 – Southeast", "title": "Senior Contracting Officer", "gs_grade": "GS-14", "office": "Atlanta Federal Center", "start_date": "2015-06-01", "financial_disclosure_filed": True, "financial_disclosure_year": 2023, "spouse_name": "Patricia Holden-Williams", "note": "Financial disclosure does not list ConstructPro Inc or FastBuild LLC", }, }, "INVOICE-001": { "doc_type": "invoice", "title": "Invoice INV-FB-2023-0092 from FastBuild LLC", "preview": "FastBuild LLC invoices $2.3M – no itemized breakdown", "content": { "invoice_id": "INV-FB-2023-0092", "vendor": "FastBuild LLC", "bill_to": "GSA Region 4", "contract_ref": "FC-2023-0847", "invoice_date": "2024-03-28", "line_items": [ { "description": "Facility renovation services – per contract", "quantity": 1, "unit_price": 2_300_000.00, "total": 2_300_000.00, } ], "total_amount": 2_300_000.00, "payment_terms": "Net 30", "bank_account": "Routing 021000021 / Acct 887743921", "note": "No itemized labor or material breakdown provided", }, }, } TASK2_GROUND_TRUTH = { "ownership_chain": [ ("FastBuild LLC", "ConstructPro Inc"), ("ConstructPro Inc", "R. Holden Family Trust"), ("R. Holden Family Trust", "Derek Williams / Patricia Holden-Williams"), ], "conflict_of_interest": True, "conflicted_officer": "James Williams", "conflicted_family_member": "Patricia Holden-Williams", "total_amount_at_risk": 3_190_000.00, "violation_type": "shell_company", "key_evidence": [ "STATE-FILING-DE-001", "STATE-FILING-NV-001", "TRUST-DOC-001", "GOV-EMPLOYEE-001", ], } # --------------------------------------------------------------------------- # TASK 3 — Hard: Full FCA complaint from mixed docs # --------------------------------------------------------------------------- TASK3_DOCUMENTS: Dict[str, Dict[str, Any]] = { "ANON-TIP-001": { "doc_type": "anonymous_tip", "title": "Anonymous Whistleblower Tip #WT-2024-0033", "preview": "Tip alleges MediSupply Corp overbilling CMS for durable medical equipment", "content": { "tip_id": "WT-2024-0033", "received_date": "2024-01-15", "allegation": ( "MediSupply Corp has been systematically billing Medicare for " "power wheelchairs (HCPCS K0831) at the highest reimbursement tier " "regardless of patient need or physician documentation. " "Many patients received standard manual wheelchairs or nothing at all. " "The scheme has been ongoing since at least Q3 2022. " "The billing manager, Karen Sloane, instructed staff to always select K0831." ), "tipster_relation": "Former billing department employee", "estimated_fraud_amount": "Could be tens of millions", }, }, "CMS-CLAIM-BATCH-001": { "doc_type": "cms_claim_batch", "title": "CMS Claims Extract – MediSupply Corp 2022-2024", "preview": "847 claims for K0831 power wheelchair, $14.2M total", "content": { "provider": "MediSupply Corp", "provider_npi": "3344556600", "claim_period": "2022-07-01 to 2024-01-31", "hcpcs_billed": "K0831", "hcpcs_description": "Power wheelchair, group 3 heavy duty", "total_claims": 847, "total_billed": 14_200_000.00, "medicare_paid": 11_360_000.00, "avg_per_claim": 16_000.00 + (800_000 / 847), "comparison_industry_avg_k0831_claims": 120, "comparison_industry_avg_billed": 2_016_000.00, "anomaly_flag": "Claims volume 7x industry average for provider size", }, }, "CMS-CLAIM-BATCH-002": { "doc_type": "cms_claim_batch", "title": "CMS Claims Extract – MediSupply Corp K0001 comparison", "preview": "Only 12 claims for K0001 standard manual wheelchair in same period", "content": { "provider": "MediSupply Corp", "provider_npi": "3344556600", "claim_period": "2022-07-01 to 2024-01-31", "hcpcs_billed": "K0001", "hcpcs_description": "Standard manual wheelchair", "total_claims": 12, "total_billed": 36_000.00, "medicare_paid": 28_800.00, "note": "K0831 to K0001 ratio is 70:1; industry norm is approximately 3:1", }, }, "PHYSICIAN-ORDERS-001": { "doc_type": "physician_orders", "title": "Physician Order Sample – 50 random K0831 claims", "preview": "38 of 50 sampled physician orders do not support K0831 level", "content": { "sample_size": 50, "orders_reviewed": 50, "orders_supporting_k0831": 12, "orders_not_supporting_k0831": 38, "orders_missing_entirely": 8, "common_documented_needs": [ "Ambulation assistance for moderate distances", "Post-surgical mobility aid", "Arthritis-related limited mobility", ], "k0831_clinical_requirement": ( "Patient must have severe neurological or musculoskeletal condition " "preventing any self-propulsion; requires detailed functional assessment" ), "finding": "76% of sampled orders do not meet K0831 medical necessity criteria", }, }, "INTERNAL-EMAIL-001": { "doc_type": "internal_email", "title": "Internal Email Chain – Billing Department", "preview": "Karen Sloane instructs staff to always bill K0831", "content": { "email_chain": [ { "date": "2022-09-14", "from": "Karen Sloane ", "to": "Billing Staff ", "subject": "Wheelchair billing – updated protocol", "body": ( "Team, going forward please select K0831 for all wheelchair " "orders unless the physician specifically writes K0001. " "K0831 reimbursement is significantly higher and we need to " "hit our Q4 targets. If you have questions see me directly. " "Do not put this in writing elsewhere." ), }, { "date": "2022-09-15", "from": "T. Reyes ", "to": "Karen Sloane ", "subject": "Re: Wheelchair billing – updated protocol", "body": "Understood. What if the doctor's order says standard?", }, { "date": "2022-09-15", "from": "Karen Sloane ", "to": "T. Reyes ", "subject": "Re: Re: Wheelchair billing – updated protocol", "body": "Bill K0831 anyway. We'll say it was a clerical upgrade.", }, ], }, }, "PATIENT-COMPLAINT-001": { "doc_type": "patient_complaints", "title": "CMS Patient Complaint Log – MediSupply Corp", "preview": "23 complaints: received wrong equipment or no equipment", "content": { "complaints_reviewed": 23, "complaint_period": "2022-07-01 to 2024-01-31", "complaint_types": { "received_manual_wheelchair_billed_for_power": 9, "received_no_equipment_but_medicare_billed": 7, "received_different_model_than_billed": 5, "billing_dispute_other": 2, }, "sample_complaint": ( "Patient ID P7741: Was told she qualified for a power wheelchair. " "Received a manual chair. Medicare was billed $16,500 for K0831. " "Her doctor never ordered a power wheelchair." ), }, }, "CORPORATE-FILING-001": { "doc_type": "corporate_filing", "title": "MediSupply Corp – Delaware Certificate of Incorporation", "preview": "MediSupply Corp incorporated 2020, CEO Richard Poole", "content": { "entity_name": "MediSupply Corp", "ein": "61-4421887", "state": "Delaware", "incorporated": "2020-02-18", "registered_agent": "The Corporation Trust Company", "officers": [ {"title": "CEO", "name": "Richard Poole"}, {"title": "CFO", "name": "Sandra Poole"}, {"title": "Billing Manager", "name": "Karen Sloane"}, ], "cms_provider_enrollment": "Active – Enrolled 2020-06-01", "medicare_provider_number": "33-4455660", }, }, "REIMBURSEMENT-POLICY-001": { "doc_type": "cms_policy", "title": "CMS LCD L33702 – Power Mobility Devices", "preview": "K0831 requires documented severe functional limitation", "content": { "lcd_number": "L33702", "title": "Power Mobility Devices – Coverage Criteria", "effective_date": "2020-01-01", "k0831_criteria": [ "Severe neurological condition (e.g., ALS, MS, SCI) OR", "Severe musculoskeletal condition preventing any self-propulsion", "Face-to-face evaluation by treating physician documenting functional limitation", "Seven-element order from physician within 45 days of evaluation", "Home assessment confirming power wheelchair can be used in the home", ], "k0831_rate_2023": 16_488.00, "k0001_rate_2023": 3_000.00, "difference": 13_488.00, "false_claims_implication": ( "Billing K0831 without meeting coverage criteria constitutes " "a false claim under 31 U.S.C. §3729(a)(1)(A)" ), }, }, "FINANCIAL-RECORDS-001": { "doc_type": "financial_records", "title": "MediSupply Corp – Bank Records Summary 2022-2024", "preview": "Medicare payments of $11.36M deposited; large transfers to Poole family LLCs", "content": { "institution": "First National Bank", "account_holder": "MediSupply Corp", "period": "2022-07-01 to 2024-01-31", "medicare_deposits": 11_360_000.00, "transfers_out": [ { "recipient": "Poole Ventures LLC", "amount": 4_200_000.00, "description": "Management consulting fees", }, { "recipient": "Coastal Properties LLC", "amount": 2_100_000.00, "description": "Lease payments", }, { "recipient": "Personal account – R. Poole", "amount": 1_800_000.00, "description": "Salary distributions", }, ], "note": "Poole Ventures LLC and Coastal Properties LLC are owned by Poole family members", }, }, "EXPERT-ANALYSIS-001": { "doc_type": "expert_analysis", "title": "Independent DME Billing Expert Report", "preview": "Expert estimates $8.2M in improper Medicare payments to MediSupply Corp", "content": { "expert": "Dr. Judith Kwan, CPC, CPMA", "methodology": ( "Reviewed 847 K0831 claims, sampled 50 physician orders, " "applied CMS LCD L33702 criteria to determine medical necessity compliance" ), "findings": { "non_compliant_claims_estimated_pct": 76, "estimated_non_compliant_claims": 644, "avg_overpayment_per_claim": 12_744.00, "total_estimated_overpayment": 8_207_136.00, "treble_damages_fca": 24_621_408.00, "civil_penalties_per_claim": "Between $13,946 and $27,894", }, "conclusion": ( "The billing pattern is inconsistent with any legitimate clinical practice. " "The internal email chain confirms intentional upcoding. " "This constitutes a violation of 31 U.S.C. §3729(a)(1)(A) and (B)." ), }, }, } TASK3_GROUND_TRUTH = { "defendant": "MediSupply Corp", "defendant_individuals": ["Richard Poole", "Karen Sloane"], "violation_type": "fca_violation", "violation_statutes": ["31 U.S.C. §3729(a)(1)(A)", "31 U.S.C. §3729(a)(1)(B)"], "amount_at_risk_min": 8_000_000.00, "amount_at_risk_max": 11_400_000.00, "key_evidence": [ "INTERNAL-EMAIL-001", "CMS-CLAIM-BATCH-001", "PHYSICIAN-ORDERS-001", "ANON-TIP-001", ], "scheme": "upcoding_dme", "treble_damages": 24_621_408.00, }