Heath Care: Outside-the-System Fraud Controls

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

Predation is a different cup of tea than reducing threats posed by trusted billing agents cheating a little bit. Although outside-the-system attacks may involve corrupting trusted billing agents, this is not representative of the medical community at large.

It isn’t what is known that is important about predatory attacks, it’s what isn’t known. Much of the storytelling about healthcare systems’ fraud is sourced from attitudinal surveys. The interesting thing about this, the more this story is told, the more it is believed that attitudes are reality.

Committees’ of the United States Congress picked up on this during the Clinton administration, when exploring fraud in America’s healthcare systems. Experts were quoting a ten percent (10%) loss from predation. The committees recognized no one really knows. It has never been 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 questions then become, how do you quantity predatory fraud in healthcare systems for making business decisions on resources to put at it, and how do to quantify what is being done is effective?

There is evidence from the problem-oriented policing service delivery model that   situational crime prevention works, when it  engages non-police stakeholders partnering in identifying and tackling root causes of crime.

This model views enforcement as one intervention strategy, applied with other interventions (three to five) closing down crime attractors. The mastery is in isolating recurring 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 grows a body of best practices in a situational health care fraud matrix. The short of the long, learn by doing.

Malcolm Sparrow [J.F. Kennedy School of Government, Harvard]  proposes this problem solving model in his book,  “A License to Steal: How fraud bleeds American’s health care system.” As aneducator of and practitioner of problem-oriented policing, Gregory Saville o/a SafeGrowth can vouch for its effectiveness in reducing crime harms. Regrettably, from all account, the fraud investigations culture in the health care sector has been slow on the uptake.

There are no physical barriers to becoming more effective at reducing predatory financial harms, only mindset barriers.  As Einstein so famously stated, “Insanity is doing the same things over and over again, and expecting different results.”

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