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
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
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
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
The federal government is more aggressively pursuing health care fraud, and helping the states do the same, by proposing funding changes and investing in new technologies. A newly proposed rule would allow 90 percent Federal Financial Participation (FFP) for data mining initiatives in state Medicaid Fraud Control Units (MFCU’s). Another
