Health Care Systems: Inside-the-System Billing Abuse Controls

The current experience with COVID-19, reinforces public health and health care as an integral part of our nation’s critical infrastructure. Public and private health care insurance organizations are complex systems.

These organizations are vulnerable to financial harms. This post reviews  “inside-the-system” harms.  Outside-the-system threats will be separately posted. There are times when these threats inter-relate.

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.

Aggression and cooperation are complex and chaotic to manage. 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. The message from behavioral biologists; there is no such thing as “free will” in resisting cheating temptations, and no-more-so that when resilience has been 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.

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

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