Heath Care Systems: Outside-the-System Predatory Fraud Controls (3 of 3)

This is the last in this three part series on the financial harms posed by misuse, abuse and predation. The last post explored inside-the-system threats. This post explores outside-the-system threats.

Predation is a different cup of tea than reducing threats posed by trusted billing agents being careless with resources or cheating a little bit. Although outside-the-system attacks may involve corrupted trusted billing agents, this is not representative of the billing agent  community at large.

With automated billing systems, it isn’t what’s known about predatory attacks that is important. It what isn’t known. Tragically, much of the storytelling about healthcare systems’ fraud is sourced from attitudinal surveys. The interesting thing about this, the more this story is told, these attitudes begin to define “reality.”

Committees’ of the United States Congress picked up on health care fraud hyperbole during the Clinton administration; when exploring fraud in America’s healthcare systems. Experts were quoting a ten percent (10%) loss from predation. The Committees response: No one really knows. It was never scientifically quantified. And, there is no evidence that the threat of investigation and prosecution is a stand-alone deterrent to fraud. It is little wonder risk managers and business decision makers balk at putting additional resources towards “countering fraud”, much to the angst of those struggling to control it.

The question then becomes how do you quantity efforts  to counter predatory fraud in order to determine what works and what doesn’t work?

Work has been done in this regard in a different domain. There is evidence from the problem-oriented policing service delivery model that applying situational crime prevention works; when it engages non-police stakeholders partnering in identifying and tackling root causes of crime. Traditionally this has been more the domain of uniform division in policing than in the investigations divisions. Efforts to introduce this harms reduction model to criminal fraud investigations teams servicing the health care sector fell short.

This model views “law enforcement” as one intervention strategy to be applied with other interventions (three to five) to remove crime attractors. Mastery comes in isolating recurring outlier patterns and hot spots for which projects can be undertaken and completed in six to nine months. The targeted activity is quantified going in, and outcomes measured for effectiveness in reducing harms. From it will grow a body of best practices leading to a situational health care fraud matrix. The short of the long; learning from doing.

Malcolm Sparrow J.F. Kennedy School of Government, Harvard]  proposed this problem solving model in his book,  “A License to Steal: How fraud bleeds American’s health care system.” As an educator of and practitioner of problem-oriented policing, Gregory Saville o/a SafeGrowth vouches for its effectiveness in reducing crime harms. Regrettably, the fraud investigations culture in the health care sector appears to be slow on the uptake.

In summary, from our research of privacy acts and case law defining how information may shared and used between insurers, and between insurers with police, there are no legal barriers to becoming more inter-agency cooperative in reducing predatory financial harms when following the procedures outline in our laws, only mindset barriers.

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