There has been a great deal of noise and subsequent press around healthcare fraud schemes getting larger and involving more collaborators. Much of the collusive fraud that has come to light has been taking place for years, costing millions of dollars, with very little recovery. In many cases, the conspirators flee and there is no one left to recover from – not your standard doctor billing for services not rendered.
Consider the instances where deceased provider NPI (National Provider Identifier) codes are being used to bill false claims to Medicare by organized crime. Often, the federal government pays for years without any knowledge that the actual doctor is no longer living.
We've heard a number of terms thrown around: conclusive fraud, organized crime, social networking, and more. It all sounds extreme and ominous, and brings up images of dark street corners with shadowy figures selling patient information and insulin.
Addressing this growing issue has become a serious concern. Many statistics have been published stating the increase of conclusive healthcare fraud. One of the main reasons for the increase is that healthcare fraud appears to be easier to commit and get away with than traditional financial fraud (money laundering, credit card fraud, etc.). Banks and standard insurance companies seem better at protecting their money than most healthcare organizations.
When considering collusive healthcare fraud, one of the most important aspects to keep aware of is target identification: who is committing the fraud, who is participating, and how are they conmected? Around every corner is another vendor talking about social network analysis, but the issue is not just identifying who’s associated in a network (or who is working together), but more importantly: at whom should you be looking?
Getting past marketing promises, it becomes very important for healthcare organizations to focus on solutions that present them with "aberrant" behavior across their book of business with an eye to conclusion. There appear to be no manual methods to properly identify the behavior, and then make the links required. Besides, who has the time?
Another consideration to keep in mind is what processes are in place to pursue collusive fraud if it is identified? Do you send all participating parties a bill? Not to make light of it all, but collusive fraud is much more complicated than just provider or member fraud. What is each parties level of partition, how is it measured, what actions can you take (prosecution, recovery, etc.), what is the total cost?
It appears very clear that collusive fraud in healthcare is one of the new areas where significant monies can be saved. The only question remains is, how do you do it?