Health care fraud and abuse affects some of the biggest companies and governmental agencies in the country – those with budgets and businesses measured in multi-billion dollar numbers.  Ironically the big news headlines seem to always have to do with …

In the article “Prison Sentence for Insider Crimes,” Tracy Kitten highlights the insidious nature of crimes committed by employees. So much attention is being focused on outside threats—hacking, claims fraud, ID theft—that we tend to slack off our internal monitoring duties.

So I’ve been slightly busy the last few weeks travelling for speaking engagements and writing articles. The good news is I’m back. The bad news is…health care fraud is still a serious issue. While on the road the subject most commonly discussed is how can the fight against fraud improve and my answer has remained consistent – deploy better technology.

Last week I put out a few key numbers without explaining what they represent. As Promised—this week I am providing the answers!

1949
1976
10/1/2013
14k–69k
3.8k–72k
GEMS
$5.5 B–$13.5B
1.6%

This week one of our directors, Greg McFaul, asked to share his thoughts on the latest list published by the Office of the Inspector General. I think you’ll find the following post quite insightful…enjoy!

Some time ago (okay, a long time), my dad once told me, “Son, there are some lists you want to be on, and some you don’t.” I knew what the “good list” meant: the Dean’s List, being picked to play on some team and, of course, Santa’s nice list. Intuitively, I also knew that the other list was the “not nice” list and, certainly, no gifts would be involved.

In discussing Social Network Analytics (SNA) with our customers, SNA is often confused with social networking applications such as Facebook, Twitter or LinkedIn. Far from social networking, SNA is as an advanced analytic tool that allows payers—both commercial and government—to combat fraud, waste and abuse in a broader and more transparent way than traditional approaches have previously allowed.

It’s always interesting to talk to someone from a different side of the house. I had lunch today with a gentleman that’s been in the health IT world pretty much as long as there’s been a health IT world, about 30 years. He’s spent most of this time on the delivery side of the house – hospitals, medical devices – and now is right in the middle of the EHR/HIE puzzle.

The U.S. Government Accountability Office (GAO) announced last week that roughly $48 billion of Medicare’s $507 billion budget in 2010 went to fraudulent or improper payments. In the same article, it was also noted that increased efforts towards the prosecution of Medicare fraud have netted the government $4 billion in recoveries in 2010, by far the most ever.

Last week CNN Money reported that a health care fraud crackdown netted $4 billion last year. In order for the government and commercial payers to continue preventing, identifying and eliminating fraud, waste and abuse it is critical that the industry change the way health care fraud is detected and investigated. Implementing fraud risk control measures and utilizing new technologies will fundamentally change the way health care fraud is investigated. Please view this video to hear more about how the health care industry can get better results by changing the way it approaches fraud investigations.