Category: Inside-the-System Cheating

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.

Health Care Systems: Misuse, Abuse & Predatory Fraud Controls

Health care is part of a nation’s critical infrastructure (CI). It is the largest public cash dispensing sector of the United States and Canadian economies. Ten times that of defense. Health care services delivery is an extraordinarily complex system. Within this context, conversation on misuse, abuse and predatory fraud controls must be broken down into smaller ecosystems to make sense of the issues and counter measures.

Definition: Ecosystems are, “living organisms in conjunction with nonliving components of their environment interacting with the system.”  

The United States spends in excess of 17.3% of GDP on health care. It is a complicated vertical system of public and private sector plans, where people falling between the cracks end up uninsured. The result can be physically, emotionally and financially  catastrophic for families. The United States, far and away has the most expensive per capita health care spending in the world. In his book, “A License to steal: How Fraud Bleeds America’s Health Care System”, Harvard University’s Malcolm K. Sparrow dissects the health care delivery system’s defenses from predatory crimes. His recommendations on controls are for most part unheeded across North America.

Canada spends in excess of 10.53 % of GDP on health care benefits and services. Health care spending in Canada is horizontal, with basic care for everyone meeting status and residency requirements. It is topped up by private plans for unregulated services. Increasingly larger portions of provincial funding goes to universal health care, with insidious deregulation of formerly paid publicly services. In Chronic Condition; What Canada’s Health Care System Needs to Be Dragged Into the 21st Century”, Jeffrey Simpson explores the options with a growing problem the Canadian system faces, including cuts to “nonessential” services, tax increases, various types of privatization, and finding savings within health care itself.

The next post in this series concerns inside-the-system financial harms and controls. The third in this series will open up conversation on outside-the-system financial harms and controls.