Tag: health care fraud

Ross Kaplan 0
Is fraud really the biggest issue in health care cost?

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

Analytics
Jon Lemon 0
Four-step approach to government fraud detection

Every day there are news stories of fraud perpetrated against federal government programs. Topping the list are Medicaid and Medicare schemes which costs taxpayers an estimated $100 billion a year. Fraud also is rampant in other important federal programs, including unemployment and disability benefits,  health care, food stamps, tax collection,

Ross Kaplan 0
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

Ross Kaplan 0
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.

Ross Kaplan 0
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

Data for Good
Ross Kaplan 1
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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