Going on the Offensive with Combatting Fraud

By: Benton Curtis

So often today we read press clippings from across the country on how the Department of Justice continues to crack down on health care fraud, be it in the criminal or civil arena. But this barrage of announcements, while impressive, evidences a disturbing trend that sizable providers, particularly managed care organizations, should take note of and address immediately, if they have not already. Indeed, DOJ almost always dedicates its full prosecutorial arsenal to combatting what it views as patent abuse of federal health care benefit programs, such as Medicare and Tricare. While this approach is well-intentioned and, at times, successful in terms of criminal convictions and dollars recovered, frequently absent is any desire by DOJ to assist sizable, private programs, who too, like their federal counterparts, are regularly victimized by creative scams, schemes and rackets. What can these organizations do to try and avoid this dilemma?

Be Proactive in Assessing Real Time Data – DOJ’s reigning practice to combat fraud typically begins with data analytics, but agents and attorneys normally view suspect data weeks, if not months (or years), after claims have been submitted and paid. Thus, they often are placed – through no fault of their own – in an unenviable position of addressing illicit conduct well after the fact.  Private programs should enlist a similar approach to identify statistical anomalies, but with a greater emphasis on real time distillation.  Simply put, the shorter the lag time between the actual activity in question and identification of that questionable activity, the greater the likelihood the activity can be addressed internally and referred externally for successful prosecution.

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