Health care fraud and the promise of predictive modeling

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 […]

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Policy modification for health care waste and abuse

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. […]

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How long has health care fraud been hiding under the bed?

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, […]

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Is fraud a dirty word in health care?

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 […]

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Larger fraud schemes means more money out the door

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 […]

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What happens when a health care fraud scheme changes its spots?

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 […]

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Is it fraud or abuse?

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 […]

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The value of outside information

Most health care organizations either intentionally or due to some inability don’t use outside information (not just referals) in their search for fraud.  There are great numbers of valid reasons for this: HIPAA, security, usable/current data sources, inflexible information systems or processes, restrictive compliance & IT departments, and the list […]

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The holy grail of pre-pay health care fraud

Everyone within the health care community recognizes that the traditional ‘pay-and-chase’ model for fraud cost reduction has some serious limitations.  Recovery of the lost funds is in some cases a mere single digit percentage point (with some exceptions – but not many) of the moneys paid.  And the effort and […]

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Why life cycle management matters for health care fraud analysis

Due to the rapid changes in both the health care market and more specifically the amount of fraud being committed in it, it is even more important than ever to maintain some degree of life cycle management to update the analyses used to detect and identify aberrant activity. However, many […]

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