Financial Harms Controls the Health Insurance Sector

This post calls for outside the box thinking and a shift of mindset on risk, fraud controls and investigations in the public and private health care insurance sectors.  With specific situational claims there is inter-relationship with claims in the property and casualty insurance sector, in particular with accident benefits and bodily injury claims.

The financial harms controls and enforcement today circles around the deterministic controls of cause and effect. This reductionist, linear model is bound by approximations; sometimes referred to as “gestimates”. It underachieves in what is possible in recuing financial harms in these sectors of critical infrastructure. 

One can successfully argue that linearity and extrapolation are precise enough to construct mechanical outputs. It assumes by knowing a present state, the past and future states can be projected along a straight line. Small incongruities in data can be ignored as “noise” –  that is the errors in the math calculations which are so small that it doesn’t effect building bridges, officer towers, machines and other physical constructs.

But the reality is that insurance sector payment plans are nonlinear and dynamic; the stuff of complex systems, quantum science and the mathematics of chaos. The whole is rarely the sum of the parts. The costs of controls rarely correlate directly with prevention outputs.  Thusly, payment plans are complex systems.  Consequently, complex systems thinking is the new reality for mitigating threats posed by waste, misuse and abuse.

It requires clarity to distinguish ordinarily honest people cheating a lit bit when tempted to do bad things; from predatory fraud.  Systems thinking is a move away from rational choice and  ‘whack a mole’ linearity; to better understanding the inter-connectedness and inter-dependencies between the parts, in order to reduce harms that are situational or geographic specific enough to go to war on in a few short months in ways that can measure outcomes.  

tranzform-security is an idea importing complex system thinking and prevention science to conventional controls for preventing insurance payment system waste, misuse and abuse. It draws on insights from psychology, neuroscience, social physics, mathematics (chaos) and evolutionary biology… to mention a few.   

We assist clients deep dive into health care and property and casualty insurance plan ecosystems. We help you look for the “noise” in behavioral patterns which if addressed early on prevent tipping points to more harmful future states.

Our team assists progressive risk managers, administrators and loss reduction specialists with tools to counter internal waste, misuse and  abuse.  We draw from behavioral insights to nudge  people towards higher standards of moral behavior. We bring together at team of like-minded, new science consultants to educate and assist government and business sustain cultures where it becomes more difficult to rationalize cheating when tempted to do bad things.

The Nasty Stuff – Predatory Fraud 

Predatory fraud and corruption prevention science teams works on problems of a different scale. 

The tranzform-security problem-solving approach is unique. It recognizes there is no top-down, cookie cutter solution for controlling predatory fraud. Each ecosystem inside a health care plan will have its own characteristics and “noise”, demanding different combinations of counter-measures. It is a never ending cat-and-mouse game of scan, analysis, response and assessment at levels geographically or situational specific enough to quantify the outlier activities, to identify what uniquely attracts the fraud activity to this geographical and/or situational space, and to tailor counter-measures in reduce the financial harms in projects that or doable and the results measurable for effectiveness.  

John Lyons –  The ATRiM Group

Education and fraud problem-solving helps organizations reduce the threats posed by individuals who do bad things and to tackle bands of people without moral conscience. Subject matter experts from across disciplines must collaborate with other subject matter experts to consult on data mining strategies for identifying outlier behaviors. For one, the ATRiM Group teaches/consults investigators on a unique approach with a proprietary Situational Health Care Insurance Fraud & Corruption Matrix©.

This problem-solving approach includes seamless escalation of harms civil or criminal remedies in a way that optimizes recoveries. Investigators can develop as predatory fraud problem-solvers in their organizations. They can learn to isolate problems in a way that they can be tackled in six to nine months and then measure for outcomes. The lessons learned from this planning-in-action approach to what works and what doesn’t work in each situation, rolls up into the next generation of prevention strategies, and in a way the sustains high levels of adaptability to changing attack methods.

Where to begin 

The prevention science search conference format, facilitated by prevention science facilitators, will help insurance plan administrators control  waste, misuse, abuse and to investigators become predatory fraud problem-solvers, with enforcement but one tool in the box. Participants leave with a new level of clarity the distinction between controlling cheating by mostly honest people, and reducing systematic predatory fraud.

The conference (2.5 days) helps create alignment among participants from all level in the organization. It builds the relationships necessary for designing a different future state to controlling financial harms problems. In the post-conference launch phase, we help our clients develop a planning-in-action culture to find bottom-up solutions that are situation or geographic specific enough to sink the organization’s teeth into in a way that produce measurable results.