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
The men, women and children of Datapolis are falling ill at an alarming rate, forcing me to turn my attention away from my ongoing battle with Obscuro and toward helping the Datapolis Council of Elders distribute its medicine before it is too late. As it happens, just as we most
What is the solution for patient-centric healthcare? Big data, says SAS expert Alice Swearington in the post, Treat patients with big data insights. "Service providers throughout the healthcare continuum that become patient centric first will win the patient," she explains, citing the industry tends toward insurance exchanges and retail insurance
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
For the past year, I’ve had the pleasure of serving on the communications team of the National Collaborative for Bio-Preparedness (NCB-P), of which SAS is a partner and the analytics provider. That experience was heavy on my mind as I recently watched the film Contagion. I may drop some minor
For the past year, I’ve had the pleasure of serving on the communications team of the National Collaborative for Bio-Preparedness (NCB-P), of which SAS is a partner and the analytics provider. That experience was heavy on my mind as I recently watched the film Contagion. I may drop some minor
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
As part of the staffing efforts for the new SAS Center for Health Analytics and Insights (CHAI), SAS recently hired Dr. Graham Hughes, MD, as the company’s first Chief Medical Officer (CMO). When I heard the news, I sent a few questions to Graham to learn more about the new
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
In the health care field, the impact of fraud, waste and abuse on payers -- whether insurance companies, government agencies or self-insured employers -- is enormous. Fraud losses weaken a payer’s financial position, with fraud loss estimates rivaling net income. Fraud losses feed the escalating care cost curve, undermining a
Recently I was listening to an NPR (National Public Radio) documentary about the history of cancer and medicine’s evolution in understanding and treating cancer. This was an amazing story. I would venture a guess that nearly everyone who is reading this post has been affected by cancer in one way
I am back home in Denver and catching up on all my thoughts from AHIP 2008. Every year I come back wishing I could divide my time exponentially. After all, a quick count of this year’s session tells me that I could only scratch the surface. In total, the Institute
Twice this year, I have been privileged to hear Clayton Christensen outline the principals around disruptive technologies and their impact on redefining industries. I left Friday’s closing day general session, “Diagnosing the Disease: A Disruptive Remedy for Health Care”, equally excited, reenergized yet perplexed. AHIP, again, did not fail to
As I head over to Moscone Friday morning, I keep thinking about one statistic I heard yesterday as presented by Dr. Sobel, The Permanente Medical Group: Who provides the largest source of care provision in the US? You do! 80% of all primary care is self-care. In today's age of
AHIP brings each year a bit of a surprise. In my pre-AHIP posting, I discussed the dedication to improving the healthcare system all the while your industry is being painted as the “bad guy”. That point was driven home this morning. As I was getting charged-up learning about the opportunities
An afternoon of sessions followed by the exhibit hall mania to the AHIP Opening Night Reception…..from the discussions to exhibits to the presentations, there is no doubt that the business of health insurance plans is changing…..but I am not convinced we are all on the same page as to how,
AHIP’s 2008 Institute is getting cranked up and the streets of San Fran are filling with bag-carrying registrants scurrying back and forth between their “conference hotels” (1 block to 15 blocks away) while the early session workshops are underway. This morning’s AHIP Evidence Policy “update” was a good supplement session
As we head into the week before America’s Health Insurance Plan’s annual Institute, just a few thoughts…….. How healthy is our healthcare system? It depends of course on your definition of healthy. Imagine spending 24/7 tirelessly working to improve “the system” and always being painted as the “bad guy.” What
