That simple truth is that vast sums of money are stolen from the health
care system every year. A significant proportion of each health care dollar
goes not for the provision of health care, but to criminal enterprise.

How much gets stolen? The magnitude of this problem is measured in
terms of hundreds of billions of dollars each year. How many hundreds of
billions of dollars? For the time being, nobody knows for sure. If we were
lucky, perhaps just one hundred billion. More likely, two or three. Quite
possibly four, and conceivably five. (That would be $500,000,000,000.)

My examination of this subject began seven years ago with two re-
search grants from the National Institute of Justice (NIJ). The task was to
examine the state-of-the-art of fraud controls used within the health
care industry. That task, and my continued involvement with the issue
since, has taken me to countless major national conferences over the last
nine years. Even when attendance at such conferences runs close to a
thousand, I am invariably the only "academic" present, and I am often
asked by other attendees why I am there. The reason I have been there
seems all too plain: I believe this is an important public policy problem,
a potentially massive drain on the nation's health care resources. Health
care fraud not only bleeds the system but also represents a colossal injus-
tice as crooks enrich themselves at taxpayers' expense. Surely the ques-
tion should be, "Why are there not more serious researchers paying at-
tention to this problem?"

One possible answer, I suppose, is that because fraud control does not
fit neatly under the rubric of criminal justice, health care policy, medi-
cine, public administration, economics, political science, or other well-
established academic disciplines, no one has ever really studied it before.
None of the officials responsible for controlling fraud within the
Medicare or Medicaid programs, nor anyone within the commercial in-
surance industry, ever took "Fraud Control 101" in college, because no
one ever taught it. Within the industry, one can find training on fraud in-
vestigation, but very little attention to fraud control. Investigation focuses
on the cases that come to light (i.e., the visible slice of the pie), whereas
control focuses on the invisible mass. With health care fraud, as with
many other forms of white-collar crime, what you see is not the problem.
The problem, by its very nature, is largely invisible, and we make a grave
mistake if we inform ourselves about the problem only by paying atten-
tion to what comes to light. Fraud control, as a science, is little studied; as
an art, it is scarcely appreciated. It is hardly yet even a subject, though--
as we shall see--it presents an extraordinary array of complicated intel-
lectual challenges.

-viii-