License to Steal: How Fraud Bleeds America's Health Care System

By Malcolm K. Sparrow | Go to book overview

5
The Pathology of Fraud Control

This part of the book is for those who want to understand the nature of the fraud-control business and who may have already discovered that there is precious little instruction in that art available. To contemplate the underlying nature of the beast, let us for a while step back from the immediate issues of the day. The objective for this chapter is to develop some understanding of what makes fraud control in general so difficult, and what makes fraud control within the health care industry even more so.


Essential Character of Fraud Control

Fraud control is a miserable business. Failure to detect fraud is bad news; finding fraud is bad news, too. Because news about fraud is never good, senior managers seldom want to hear it.

Institutional denial of the scope and seriousness of fraud losses is the norm. In the course of my field work within the health industry, many interviewees explained how their own views differed from "the official position" of their organizations and how uncomfortable they felt telling what they saw as "the truth," even to their own management. Investigators in Florida described how only recently, after years of media attention to the concentration of fraud problems in southern Florida, has it become acceptable to "speak up" during interagency meetings. Previously, they explained, if you talked honestly about the prevalence of fraud, you immediately got blamed for having failed to prevent it.

Employees closest to the work of fraud control habitually feel frustrated, unappreciated, sometimes ostracized by their own organizations,

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License to Steal: How Fraud Bleeds America's Health Care System
Table of contents

Table of contents

  • Title Page iii
  • Contents v
  • Preface vii
  • Introduction - Who Steals, and How? 1
  • Part One - The State of the Art 37
  • 1 - Control Failures 39
  • 2 - How Goes the War? 56
  • Part Two - New Frontiers for Control 81
  • 3 - False Claims 83
  • 4 - Managed Care 98
  • Part Three - The Nature of the Fraud-Control Challenge 115
  • 5 - The Pathology of Fraud Control 117
  • 6 - The Importance of Measurement 143
  • 7 - Assessment of Existing Fraud-Control Systems 162
  • 8 - The Antithesis of Modern Claims Processing 183
  • Part Four - Prescription for Progress 201
  • 9 - A Model Fraud-Control Strategy 203
  • 10 - Detection Systems 228
  • Conclusion 253
  • Acronyms and Abbreviations 257
  • Notes 259
  • Index 277
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