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 the word fraud.  The two primary reasons are:

  1. Many or all of the doctors in a region are employees of the state (public servants) and are not fee for service.  So they are not only less able to appropriate large amounts of money from their position in medical community, but also many countries are very hesitant to openly provide negative commentary of their government workers.
  2. Some medical associations have more authority and influence in certain regions.  Clearly medical associations (like the AMA, American Medical Association) all have a tremendous amount of influence.  However, in some regions it is even more significant, to the point where doctors are considered to be so significant as to be beyond reproach.  Clearly not all Health care fraud is orchestrated by doctors, but to say none is, is simply an act of denial.

The conflict arises when health care organizations are aware that outright fraud exists but are unable to call it such, and are therefore unable to address it directly. This greatly limits their ability to prevent or pursue illegal health care activities.  Clearly doctors are worthy of respect, they are highly educated and perform a significant public service.

But then that raises the question are they immune from scrutiny? At what point does the significance of the majority (good doctors) safeguard the aberrant behavior of the minority?


About Author

Ross Kaplan

Principal Solutions Architect

Ross Kaplan serves as the Principal Global Solutions Architect for Health Care in the SAS Security Intelligence global practice. He supports health care cost containment (Payment Integrity) initiatives across the Health & Life Sciences, State and Local Government, and Federal Government verticals. He has been active across North America, Europe, Middle East, Asia Pacific and South Africa. Providing industry expertise and vision at conferences and directly to customers, Ross has been at SAS for over eight years Ross is a 16 year veteran in the health insurance industry, focusing on analytics in health and condition management, member retention, and provider profiling prior to specializing in health care. He has assisted health plans, federal and State and local government agencies in defining their requirements and providing guidance in their solution advancement. Ross is also trained and experience in Healthcare privacy laws. Prior to SAS, Ross served as a solutions architect at Computer Associates and Siebel Systems, working with the Fortune 1000. He has supported other industries such as Insurance, Banking, and Pharmaceutical. However, his primary focus has always been in health care, receiving training in HIPAA and having direct input in Siebel’s health care product development. Ross has been featured speaker at many industry events focused on health care cost containment and payment integrity, most recently on the topic of social network analysis and link analysis, predictive analytics, and fraud/waste and abuse in the European market. Ross earned a bachelor's degree in Business Administration, with a concentration in Computer Information Systems (CIS) from San Francisco State University and his Master’s Degree in Statistics as well as an MBA with a concentration in Systems Analysis. Sales Training: • Consultative Selling • The Customer Delight Principal • Major Account Sales Strategy

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