Health Care Systems: Inside-the-System Billing Abuse Controls (2 of 3)


This is the second of three articles addressing human cheating and predatory practices causing financial harms to health care systems.

This post explores “inside-the-system” harms.  The third in this series will review “outside-the-system” harms. This reference to “systems” is important.  Becoming effective and controlling financial harms requires complex systems thinking. This is the world of nonlinearity and developing anti-abuse/misuse and fraud learning cultures.   Mitigating these two different types of harms are not that same, while and at same time cannot be considered separately. The stuff of complex thinking – requires a deep understanding the relationship between parts.

Efficient delivery of health care is built on trust that diagnosing physicians/practitioners and other services providers, here-to-after referred to as billing agents, will do the right thing. It is hard to imagine this system working in any other way.

Reciprocal cooperation , also referred to as reciprocal altruism, is complex and chaotic. Cheating is everywhere in nature. Administrators should anticipate trusted billing agents cheating a little bit. They should expect cheating to increase if they believe their peers are cheating. When people are reminded of their morality close to the time of a temptation, cheating goes down. The message from behavioral biologists; there is no such thing as “free will” in resisting cheating temptations, and no-more-so than when resilience is depleted.

If not handled well, controls administrators do more harm than good, first with negative relationships providing rationalizations (excuses) when trusted billing agents are tempted to do bad things. Secondly, if offended cooperation decreases in reducing other types of misuse and abuse, both inside the system (corruption, fraud and workplace sabotage), and from outside the system (beneficiary abuse, enterprise medical crime networks, regional gang activity such as accident benefits and bodily injury claims, and at the top of the predatory food chain – transnational organized crime).

In the late 1970s, Robert Alexrod’s now famous game theory tournaments searched for effective everyday cooperation models. This came out of initial insights learned from playing out Prisoner’s Dilemma. The “tit for tat’ reciprocal cooperation model that emerged was evidenced by behavioral biologists and ethologists observing animals in their natural environments. The ultimate game theory model today is generous (forgiving) tit for tat’. It wins out every time in reciprocal cooperation, game theory modelling.

Perhaps there are lessons to be learned here on how to develop cooperative relationships with trusted billing agents.

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