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

By Malcolm K. Sparrow | Go to book overview

8
The Antithesis of Modern Claims Processing

Fraud investigators throughout the industry readily acknowledge that they only see a fraction of the fraudulent claims running through their claims-processing systems. They realize the fragility of detection and referral mechanisms; they bemoan the primacy of efficiency as the goal for the claims-processing system; and they see staff in other functions as oblivious of the fraud problem. The investigators, closest to the realities of the streets, know full well that their fraud-control apparatus--fragmented and understaffed--barely scratches the surface.

Against that depressing backdrop, the confident claims of managers at one particular insurer came as a stunning surprise. I shall refer to the insurer as Company X because the anonymity of the sites was a condition under which I visited them to conduct my fieldwork. Managers at Company X claimed that their fraud-control systems detected around 80 percent of the fraudulent claims submitted to them. They felt they had fraud under control; no other company I visited came anywhere near making such claims. Could such confidence be justified? Perhaps they were deluding themselves. Or perhaps they had such terrible detection apparatus that they really had no sense of the magnitude of the fraud problem. Or perhaps, conscious of the company's reputation, they were merely putting forward the "official position." They could not prove that they stopped 80 percent of the fraudulent claims because they, like everyone else, had no systematic method of measuring the overall level of fraud losses. They saw only what their detection systems showed them. However, company X differed from all the other insurers in several ways, not just in its confidence about fraud control. Its entire claims-processing apparatus was unique and, in many respects, represents the antithesis of modern claims processing.

-183-

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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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