A Model Fraud-Control Strategy
The preceding chapters have focused on diagnosis of the problems and assessment of current conditions rather than on prescriptions for improved controls. If the book were to end here, the parting picture would be gloomy indeed: criminals feeding off the health care system, largely with impunity; criminal fraud in the system essentially uncontrolled; control systems offering little protection to the public or insurers who place their faith in them; theft on a massive scale and at the speed of light through electronic claims processing; managed care producing forms of fraud potentially much more dangerous to human health; and the scale of government's interventions to date insufficient to make a serious dent in the problem.
The goal of earlier chapters was to produce a clear understanding of the challenge and complexity of fraud control and to provide an honest and realistic evaluation of existing control systems. Nevertheless, many prescriptive observations emerged along the way, and it is time now to pull these together and present them as a coherent whole. The task for this chapter, however, is more ambitious than merely compiling and presenting miscellaneous prescriptive recommendations. The task here is to define a model fraud-control strategy. To be of use, the strategy must offer the promise of effective fraud control and be suitable for broad use throughout the health care industry.
Almost all the elements of this model strategy exist somewhere in private insurance companies or government programs; the strategy as a whole, however, can be found nowhere. It does not yet exist. This control strategy is new, and adopting it will require managerial courage, commitment, and persistence. For most insurers, adopting this kind of fraud-