Historically healthcare has been most ‘self’ motivated to improve its ‘cost containment’ processes and methods. This is evident from the significant gap that exists between the technology and process in finance versus healthcare. Many healthcare organizations (either government or commercial) are not ‘profit’ oriented – take the Blues for example,
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Health care fraud is often depicted as the great, five-headed hydra in Greek mythology. When you cut off one head, two more grow back. But more to the point, health care fraud has been presented as one of the primary (if not the primary) causes of unnecessary healthcare spend. However, just because
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
It has become clear after speaking with numerous health insurance carriers, both in the United States and beyond, as well as at conferences (such as NHCAA), that there is a mass movement towards the nirvana that is "predictive modeling." Now that our industry is realizing the importance of predictive modeling
In the United States, loss prevention trends in health care have seemed very loudly directed at health care fraud, and less so about waste and abuse. This may be for many reasons: if you’re a private carrier, fraud prevention allows for larger recoveries and greater avoidance of future lost revenues.
It has become more and more apparent, country by country and state by state, that many organizations do not have a clear grasp on what their exposure is to health care fraud. Whatever name it goes by – aberrant behavior, abuse, waste or fraud – and no matter how it is measured – in currency (dollars,
It is becoming clear that a fair percentage of the health care community, particularity outside of the United States, are uncomfortable using the word, “fraud.” Instead, you see the words "risk" and "error" used more often to describe fraud. There appear to be many different reasons for the discomfort with
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
In most of the articles and press pieces that speak of health care fraud, the topic is usually covered in broad terms regarding the type or activity that has taken place: over-billing to Medicare/Medicaid, services billed and not delivered, over subscription of medication (by members or Pharmacies), and the list
When discussing fraud and abuse, it often (very often) becomes a philosophical discussion of whether aberrant activities are fraudulent or abusive. The quick difference being that fraudulent is intentional and abuse is not. The distinction quickly becomes an issue of legal and illegal as opposed to right and wrong. What