Health care consumerism: engaging the real buyers--employees

Many employers have begun moving toward health care consumerism strategies designed to encourage employees to take more responsibility for their health care and the cost of that care. Recent surveys suggest ways employers can ensure their consumerism strategies succeed in engaging employees and, ultimately, encourage employees to change their behavior. This article describes what those surveys reveal about employer and employee perspectives on consumerism and suggests steps employers can take to align their interests with those of their employees in order to manage the demand for and use of health care.     

Do Sentiments Matter in Fraud Detection? Estimating Semantic Orientation of Annual Reports

We present a novel approach for analysing the qualitative content of annual reports. Using natural language processing techniques we determine if sentiment expressed in the text matters in fraud detection. We focus on the Management Discussion and Analysis (MD&A) section of annual reports because of the nonfactual content present in this section, unlike other components of the annual reports. We measure the sentiment expressed in the text on the dimensions of polarity, subjectivity, and intensity and investigate in depth whether truthful and fraudulent MD&As differ in terms of sentiment polarity, sentiment subjectivity and sentiment intensity. Our results show that fraudulent MD&As on average contain three times more positive sentiment and four times more negative sentiment compared with truthful MD&As. This suggests that use of both positive and negative sentiment is more pronounced in fraudulent MD&As. We further find that, compared with truthful MD&As, fraudulent MD&As contain a greater proportion of subjective content than objective content. This suggests that the use of subjectivity clues such as presence of too many adjectives and adverbs could be an indicator of fraud. Clear cases of fraud show a higher intensity of sentiment exhibited by more use of adverbs in the “adverb modifying adjective” pattern. Based on the results of this study, frequent use of intensifiers, particularly in this pattern, could be another indicator of fraud. Moreover, the dimensions of subjectivity and intensity help in accurately classifying borderline examples of MD&As (that are equal in sentiment polarity) into fraudulent and truthful categories. When taken together, these findings suggest that fraudulent MD&As in contrast to truthful MD&As contain higher sentiment content. Copyright © 2016 John Wiley & Sons, Ltd.     

Will employee choice and defined contribution health plans salvage the embattled managed care system?

Defined contribution or consumer-driven health approaches will shift to employees not just the risks and rewards of the managed care system, but also decisions that will determine whether that system can survive. This article reviews the current state of the employer-sponsored health care system, describes defined contribution and consumer-driven health plan concepts, and outlines the approaches and steps employers can take to implement them. The author argues that, if fully implemented, such approaches could salvage the embattled managed care system by giving employees a financial stake in controlling medical costs while educating them to wisely take control of health plan spending decisions.     

Why Are Managed Care Plans Less Expensive: Risk Selection,Utilization, or Reimbursement?

This article develops a new method of decomposing the cost difference between HMO and non‐HMO plans into observed risk selection, unobserved risk selection, utilization differences, and differences in provider reimbursement rates. We implement this method using a large national sample of employer‐sponsored health insurance enrollees from the Community Tracking Study Household Survey. We find no evidence that HMO plans attract a disproportionate share of low‐risk enrollees; the US$188 difference between HMO and non‐HMO medical expenditures per enrollee can be explained by the relatively low provider reimbursement rates paid by HMO plans. This indicates there may be little need for employers to risk adjust insurance premiums or otherwise restrict employee choice of plan types.     

基于成本—收益理论的社会医疗保险欺诈问题研究

通过引入成本—收益理论,对社会医疗保险制度中的欺诈问题进行研究,比较该制度中各参与主体的成本、收益构成,分析各影响因子对欺诈与反欺诈行为的影响,研究表明:欺诈与反欺诈行为受行为成本、行为收益大小的制约,且有其相应的约束条件。在此基础上,提出了相应的反欺诈对策。     

Spousal surcharge programs--an overview

Spousal surcharge programs help employers whose goal is to provide "above-average" health benefit plans by limiting the potential "financial leakage" liabilities from covering the spouses of employees who are eligible for other health care coverage. Spousal surcharge programs are just one alternative available to help employers manage the rising cost of providing health care coverage to dependents. This article explores the prevalence, plan design, financial implications, administrative and other considerations in implementing a spousal surcharge program.     

Managing health and welfare plans instead of letting them manage you

The explosive growth and change in the health care provider industry is presenting a considerable challenge to employers that manage these benefits for their employees. Corporate mergers, supportive federal and state legislation expanding benefit availability and access to new consumer markets are a few of the forces changing the shape of the industry. Furthermore, participants are more knowledgeable about their benefit plans and are more vocal about their needs. The authors discuss these challenges and possible solutions for the employer that is attempting to determine how plan delivery and management needs can be served in a way that supports business environment and strategy.     

The impact of corporate fraud on director‐interlocked firms: Evidence from bank loans

We examine the impact of corporate fraud committed by one firm (the “fraudulent firm”) on other firms with interlocking directors (the “interlocked firms”), focusing on the debtholder side. We argue that the revelation of a fraudulent firm's fraud can damage the reputation of the interlocked firms because corporate governance can propagate via director interlocks. Empirically, we find that the interlocked firms' cost of debt is higher and the loan covenants become stricter after the fraud cases of the fraudulent firms are revealed. Consistent with the corporate governance propagation explanation, our results are weaker (stronger) for interlocked firms that have better (worse) pre‐event corporate governance standards. Our findings suggest that corporate fraud of fraudulent firms can affect other firms through director‐interlocks beyond shareholder value.     

Employee communications and health care reform

The Patient Protection and Affordable Care Act (PPACA) has made health care reform a reality. Although many of PPACA's details are still unclear to many employers, and most of the act's major reforms will take effect over the next several years, companies have reason to begin preparing for change and enough information to begin a communications effort with employees. The authors describe a number of immediate actions that employers should take to make the most of their own understanding of PPACA as it develops, as well as help their employee benefits leaders make the most informed decisions about when and how to communicate with employees about the law and its impact on their group health plan coverage.     

Outlier detection in healthcare fraud: A case study in the Medicaid dental domain

Health care insurance fraud is a pressing problem, causing substantial and increasing costs in medical insurance programs. Due to large amounts of claims submitted, estimated at 5 billion per day, review of individual claims or providers is a difficult task. This encourages the employment of automated pre-payment controls and better post-payment decision support tools to enable subject matter expert analysis. This paper presents how to apply unsupervised outlier techniques at post-payment stage to detect fraudulent patterns of received insurance claims. A special emphasis in this paper is put on the system architecture, the metrics designed for outlier detection and the flagging of suspicious providers which may support the fraud experts in evaluating providers and reveal fraud. The algorithms were tested on Medicaid data encompassing 650,000 health-care claims and 369 dentists of one state. Two health care fraud experts evaluated flagged cases and concluded that 12 of the top 17 providers (71%) submitted suspicious claim patterns and should be referred to officials for further investigation. The remaining 5 providers (29%) could be considered mis-classifications as their patterns could be explained by special characteristics of the provider. Selecting top flagged providers is demonstrated to be a valuable as an targeting method, and individual provider analysis revealed some cases of potential fraud. The study concludes that, through outlier detection, new patterns of potential fraud can be identified and possibly utilized in future automated detection mechanisms.     

Aufdeckung von Versicherungsbetrug bei Kfz-Schäden mit Hilfe des Benford-Tests

The German Insurance Association estimates a yearly amount of damage of € 1.5?bn to German motor vehicle insurance companies because of systematic fraud by insurance holders. It is supposed that about 10% of submitted claim applications contain manipulated data, therefore insurance companies are forced to complete a detailed and cost intensive case-by-case review of each single application. An alternative method to detect fraud in empiric data is the method of digital analysis based on Benford’s law. The Benford method uses a mathematical law of specific logarithmic distribution attributes of first digits. According to this approach, the data of a Benford set confirm with the expected digit distribution, if the data is not manipulated, whereas fraudulent interventions lead to a deviation from Benford’s law. Hence, until now there has not been any investigation whether the Benford method can also be applied on insurance data. The present article analyses a dataset consisting of more than 120,000 damage claim applications to answer this question as well as to identify the impact of specific characteristics on the probability of fraud contained in claim applications, such as the repair of the vehicle in a franchised or an independent workshop, the vehicle brand or the examination by insurance companies experts. Indeed it could be shown that Benford’s Law is only applicable on second digits of insurance data, but delivers very strong results here: All results of the considered characteristics could be verified by plausible arguments. For this reason insurance companies can benefit from making use of the Benford method to identify those claim applications with a high probability of fraud, which should then be reviewed in more detail so that resources can be allocated in a much more cost efficient way.     

Living with GASB 45: how to manage liabilities associated with retiree medical benefits

The Governmental Accounting Standards Board Statement 45 (GASB 45) obliges public employers to disclose liabilities related to postretirement medical benefits. Most state and local government entities are beginning to analyze and quantify how GASB 45 liabilities will affect their balance sheets and credit ratings. This article describes the many ways to reduce those liabilities without eliminating retiree medical plan benefits altogether. Now is the time for employees and employers to work together and make difficult choices for keeping retiree medical costs and GASB 45 liabilities manageable.     

Education and advice under ERISA for employee-directed 401(k) plans

Section 404(c) regulation sets forth the conditions that plan fiduciaries must meet to be relieved of liability for the consequences of employees' control over their accounts. After reviewing applicable laws and regulations, the author concludes that employers desiring to provide employees with education and/or advice services through a third party should be able to do so while still obtaining reliance on the protections of Section 404(c) and without taking on significant additional fiduciary responsibilities.     

Detecting insurance fraud using supervised and unsupervised machine learning

Fraud is a significant issue for insurance companies, generating much interest in machine learning solutions. Although supervised learning for insurance fraud detection has long been a research focus, unsupervised learning has rarely been studied in this context, and there remains insufficient evidence to guide the choice between these branches of machine learning for insurance fraud detection. Accordingly, this study evaluates supervised and unsupervised learning using proprietary insurance claim data. Furthermore, we conduct a field experiment in cooperation with an insurance company to investigate the performance of each approach in terms of identifying new fraudulent claims. We derive several important findings. Unsupervised learning, especially isolation forests, can successfully detect insurance fraud. Supervised learning also performs strongly, despite few labeled fraud cases. Interestingly, unsupervised and supervised learning detect new fraudulent claims based on different input information. Therefore, for implementation, we suggest understanding supervised and unsupervised methods as complements rather than substitutes.     

Erklärungsansätze für vertragswidriges Verhalten Versicherungsnehmern aus Sicht der ökonomischen Theorie

The two main purposes of this paper are an introduction to the economic analysis of insurance fraud and furthermore a derivation of factors that determine fraudulent behavior of policyholders on insurance markets. Consequently, we analyze the strategic decision problems of insurance companies and the policyholders and identify some factors that can help to reduce fraudulent behavior. In this context we evaluate two derived starting points for the combat against insurance fraud: fraud detection systems and a consequent charge policy of detected defrauders. We illustrate that both points can help to reduce the cost of fraud. Furthermore, we enhance our earlier analysis with respect to the empirical fact that some individuals care about fairness or — in the insurance fraud context — the legitimacy of their actions. Surprisingly, in some market situations these concerns of some policyholders do not lead to a lower fraud probability. Finally, we discuss how and to what extent insurance companies can influence such ethical concerns of policyholders. On that score, we distinguish insurance specific and insurance unspecific factors and their impact on the consumers attitudes towards insurance fraud.     

Providers’ affiliation,insurance and collusion

This paper provides a theoretical analysis of the benefits for an insurance company to develop its own network of service providers when insurance fraud is characterized by collusion between policyholders and providers. In a static framework without collusion, exclusive affiliation of providers allows insurance companies to recover some market power and to lessen competition on the insurance market. This entails a decrease in the insured’s welfare. However, exclusive affiliation of providers may entail a positive effect on customers’ surplus when insurers and providers are engaged in a repeated relationship. In particular, while insurers must cooperate to retaliate against a fraudulent provider under non-exclusive affiliation, no cooperation is needed under exclusive affiliation. In that case, an insurer is indeed able to reduce the profit of a malevolent provider by moving to collusion-proof contracts when collusion is detected, and this threat may act as a deterrent for fraudulent activities. This possibility may supplement an inefficient judicial system: it is thus a second-best optimal anti-fraud policy.     

Employer involvement in defined contribution investment education

In this paper the authors consider the personnel problems that may arise for defined contribution plan sponsors if major market corrections cause older employees to delay retirement beyond previous expectations. We move from that basic premise to argue that, given the continued evolution from defined benefit (DB) to defined contribution (DC) retirement plans, employers need to be more "proactive" in educating their employees about their retirement planning. A human resources perspective is used to support this argument, apart from and in addition to legal considerations such as ERISA Section 404(c). Specifics of employer involvement and its place as a component of an organization's culture are discussed. Finally, recommendations are given for employers to consider.     

Helping tomorrow's retirees manage "distribution phase" risks

Much of employers' attention has focused on helping employees manage the accumulation of 401(k) plan assets rather than on helping them manage the distribution phase--the period during which employees begin drawing down their 401(k) savings to meet their retirement needs. Assisting employees in managing the distribution phase can play an important role in helping employers meet a range of workforce planning goals and ensuring a maximum return on the retirement dollars that have been invested by both employees and the company. By implementing a properly structured approach to help employees manage the distribution phase, employers can help them maximize the value of their retirement savings at little or no employer cost, thanks to the leverage of the company's group purchasing power and the tax advantages of employer-sponsored plans.     

Integrating benefits decision making

Integrated employee benefit decision making helps employees use their benefits more wisely and identify opportunities to balance their immediate benefits needs (such as health care) and future benefits needs (such as retirement). This article discusses how employers can overcome employees' behavioral barriers to making integrated employee benefit decisions by changing the ways benefits are communicated and employees are presented with action decisions. Undertaking these steps allows employers to not only improve their employees' overall financial perspectives, but also furthers plan sponsors' goals of actively promoting personal responsibility with respect to retirement funding and changing employee behavior with respect to controlling health care costs.