The U.S. health care market has always had practices in place to try and manage, or at least limit, aberrant behavior, which includes activities that are often described as cost containment, payment integrity and affordability.   

In the past, many organizations have appeared satisfied with their efforts in this area and have taken offense at any insinuation that they're not performing at optimum levels. 

When looking overall at aberrant behavior, however, studies suggest that fraud accounts for five to ten percent of cost of claims, whereas waste and abuse account for anywhere from twenty to thirty percent. You could dispute the numbers, since no one can accurately calculate the exact number (hence the range).  Clearly, though, the waste and abuse portion accounts for a larger exposure than fraud.

Why then do so many organizations insist that their detection and deterrence of waste and abuse is effective but claim their fraud efforts still needs work?  In many cases it appears defensive in nature (you can never call the baby ugly), since fraud is caused by external forces and waste/abuse is due to more internal inefficiencies.

However, this trends has seemed to be changing over the last few years, perhaps due to the increase competition caused by the Affordable Care Act or by the visibility (and consequent hostility) to the perpetual increase in health care costs.  Whatever the reason, many more organizations seem interested in re-evaluating how they analyze and manage aberrant behavior.

It’s nice to see the health care industry start to behave in a more aggressive fashion to address claims leakage. Of course, the question now becomes, can health care organizations really question their methods and change their processes?