Medicare Fraud Prevention Has Cases Falling Through the Cracks–Looks Who’s Getting the Contracts And Check Out the Algorithms For Their Profitable Business Models

I guess it’s time to revisit a post I made back in January asking the question of how can a for profit company, traded on the stock exchange, be a solution to efficiently help prevent fraud when stockholder profits are the #1 priority? There are a ton of companies providing audit services for medical claims and they secure a transaction fee for that service and that is money that goes to their bottom line. In addition private insurance companies run and administrate Part D and we don’t want to catch too many crooks or else the transaction fees could suffer. This is something to give some thought to here.

It’s all about those algorithms and risk management and how to maximize profits so what is the incentive to put too many fraudulent folks out of business?

Little Progress on Fighting Healthcare Fraud – Look At Who’s Getting the Anti-Fraud Contracts

Below are a couple paragraphs from that post.

“Health Insurance and preventing fraud need to work together and you almost need some non profit organizations to have this be successful and truly look out for the consumer interest. What are we doing here, awarding contracts to companies that have created a backlog of legal court cases and potentially misrepresented themselves, to contribute to the fact that progress is moving at a snail’s pace with anti fraud solutions?

One prime example that has been in the news for years and has a ton of lawsuits in court is the case of the corrupted Ingenix data base, where the Attorney General of New York brought this to light. This data base was used for 8-9 years to calculate out of network customary charges, not only for their own claims (United) but all the other major carriers subscribed to it as well and now it is going to be revamped to be run by a non profit, and yet the company secures contract with hospitals and government entities to fight fraud? Remember, shareholder profits come first, so if there’s some money to be saved here it comes after priority #1 has been satisfied. I’m only connecting dots here with multitudes of articles that have been posted for a number of years.”

This guy (Gingrich) isn’t getting it right either, it’s those algorithms that run the direction of the business. We all know one thing in all of this and that is the fact that crooks make better billers as they don’t see patients and only have one focus, crime and making money, not healthcare.

Newt Gingrich Gets Healthcare Value Bass Ackwards–It’s All About Those Algorithms

By the way I have never seen anyone wearing 2 pairs of glasses like this before as Senator Grassley is pictured here reviewing documents.

When the new HHS director was put in place I said we needed someone with strong Health IT in that job since about 70-80% of that job will revolve around working with mathematical algorithms and here we are today full circle.

There’s simply no purpose in making statements of intent without the tools you need to back it up and that is software and audit tables to keep everyone in check.

If we put too many crooks out of business too soon, do you think that will also end up cutting some transaction money, of course it will. Google wouldn’t exist today were it not for their algorithms and they build really good ones that we all depend upon every day for valued information and some of their algorithms are healthcare related, so once we can get past the political arena here and see where the decision making processes are coming from rather than just an over all political statement, maybe we can get somewhere. Long and short of it there’s more money with instituting programs like this for more revenue production and what do they get for catching crooks, a nice pat on the back and a loss of transaction fees that pay for the hi tech end of things that is supposed to be auditing to catch crooks.

UnitedHealthCare To Use Data Mining Algorithms On Claim Data To Look For Those At “Risk” of Developing Diabetes – Walgreens and the YMCA Benefit With Pay for Performance Dollars to Promote and Supply The Tools

I think that about sums it up on why crime prevention is not going anywhere in a hurry as perhaps many turn a blind eye in that direction as the focus is to generate dividends here and this part of the battle doesn’t get anywhere. BD

Private industry is not law enforcement, they make money.

WASHINGTON — They don't seem that interested in hot pursuit. It took private sleuths hired by Medicare an average of six months last year to refer fraud cases to law enforcement.

According to congressional investigators, the exact average was 178 days. By that time, many cases go cold, making it difficult to catch perpetrators, much less recover money for taxpayers.

A recent inspector general report also raised questions about the contractors, who play an important role in Medicare's overall effort to combat fraud.

Out of $835 million in questionable Medicare payments identified by private contractors in 2007, the government was only able to recover some $55 million, or about 7 percent, the report found.

Medicare overpayments — they can be anything from a billing error to a flagrant scam — totaled more than $36 billion in 2009, according to the Obama administration.

The contractors investigate allegations of wrongdoing, acting as scouts for the government's criminal investigators. And they're also supposed to conduct "proactive" analysis to spot emerging fraud trends. For instance, they can use sophisticated computer models to scan millions of Medicare records for suspicious patterns to identify dishonest providers.