Health care fraud control: understanding the challenge

The study summarized here examined the fraud-control apparatus currently used within the health care industry, and assessed the assumptions, policies, and systems that constitute the industry's current approaches to fraud control. The objective was to develop a better understanding of the strengths and weaknesses of existing approaches. Since 1992, with Health Care Reform under debate, the issue of health care fraud has received unprecedented legislative and administrative attention. Nevertheless disturbing and somewhat surprising lapses in control persist. The fraud problem shows no sign of abatement. Background knowledge of the health care fraud issue was derived from literature searches and from four years of interaction with concerned public and private organizations. Fraud control systems, policies and procedures were examined in detail at eight field sites, representing a cross section of private, not-for-profit, and public programs. The National Institute of Justice funded the study under grant number #94-IJ-CX-K004. This study finds the science of fraud control scarcely developed and little understood by industry practitioners. Academia has paid little attention to the problem. Within the health care industry, the task of fraud control is complicated by the social acceptability of insurers as targets, the invisible nature of most fraud schemes, the separation between administrative budgets and "funds", the respectability of the health care profession, and the absence of clear distinctions between criminal fraud and other forms of abuse. Existing approaches to control are more effective in controlling billing errors, overutilization, medical unorthodoxy, and other forms of abuse than in dealing with criminal fraud. The complexity of the fraud control challenge is seriously underestimated by the health care industry Existing control systems are not targeted on criminal fraud and cannot be expected to control it. Scientific measurement of the fraud problem is a prerequisite effective control.     

Employer strategies to combat health care plan fraud

Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted.     

Profiting from destruction: The Iraq reconstruction,auditing and the management of fraud

While several US corporations have benefited tremendously from the Iraq reconstruction, the Iraqis and US taxpayers have not done as well. This paper argues that the Bush Administration's neoliberal agenda in Iraq created a corrupt, lawless environment in which corporations could reap huge profits through what would normally be called malfeasance. It further demonstrates how the audit reports produced by the Office of the Special Inspector General for Iraq Reconstruction helped to manage the impact of this massive fraud by giving the perception that the laissez-faire policies of the Bush administration were innocent mistakes, making the failures appear to be independent of one another, reconstructing corporate malfeasance as waste while criminalizing low level employees, and blaming the government agencies, the war and the Iraqis for the fraud.     

The impact of the managed care backlash on health care spending

The health spending slowdown associated with the managed care revolution in the 1990s suggests that managed care may have been successful in controlling health care spending. I exploit the passage of state regulation during the “managed care backlash” as well as geographic variation in managed care intensity to measure the impact of managed care on spending. I find that restricting managed care causes a large and significant increase in hospital spending, which cannot be explained by changes in hospital market concentration, other regulatory activity, and multiple other possible explanations. I also do not find effects of the backlash on mortality.     

Hospital Costing: Experience from the VHA

The government administered Veterans Health Administration (VHA) is the largest integrated health care system in the USA. As health care dollars are becoming tighter nationwide, VHA faces the dual challenge of achieving cost reductions and improving quality, while operating in an increasingly competitive marketplace. This places new demands on cost accountability within the agency. This paper identifies the cost accounting procedures currently used by VHA as it responds to internal budgetary curtailment and to external competitive pressures. Understanding the different costing approaches taken by the organization along with their associated problems offers lessons of interest to financial managers within and outside VHA.     

The call for innovation

To help promote innovation in health care, nursing and finance leaders can: Begin by asking the "why" and "why not" questions. Earmark dollars for experimental care models. Advocate for eliminating legal and regulatory barriers that prevent innovation.     

Risk communication in dementia care: family perspectives

Family carers are often involved in decisions concerning the health and social care needs of people with dementia. These decisions frequently involve considering risks inherent in daily living situations and discussing these with care recipients and professionals. The purpose of this study is to understand the risks that present most concern to family carers; explore attitudes and approaches of this group towards risk; and examine how information about risks is shared between familial carers, care recipients and professionals working in dementia care. Five focus groups were held across Northern Ireland between April and July 2015 involving 22 carers. Risks of most concern were driving, falls, financial risks, getting lost and using electrical appliances. Concepts of ‘risk’ related to terms such as danger, harm and vulnerability with emphasis on consequences rather than likelihoods. The psychosocial benefits of taking risk were recognised by some participants. Discussion of risks with family members with dementia primarily involved bringing risk matters to the attention of the individual. Family carers talked with a wide range of professionals about risks. Divergences in perspectives were noted, particularly in relation to matters of health and safety. A model of risk communication is developed illustrating how this can play a key role in informed, shared decision-making where a family member has dementia, serving an important role in risk management processes in informal community dementia care.     

“Long-Term Yield Rates for Actuarial Valuations”, Jacques F. Carriere,July, 1999

Abstract

This paper explores the relative significance of aging as a determinant of financial cost of health care beyond age fifty, with particular attention to the effect for ages 65 and over. The paper presents concepts of aging factors and aging curves, which define relative values between ages for utilization or cost of health care services. General conclusions are drawn from Medicare data that utilization and cost differ by age, but that aging factors vary across services and may be less significant at the very old ages. The author then turns to the question of measuring the significance of an aging curve assumption and what accuracy is lost in the simpler alternative of a single value across an age range. The practical effects of relative value aging curves are examined through hypothetical examples of increasing complexity in a retiree health valuation. A method to measure the impact is put forth. Three important variables are discussed in some detail. A survey to ascertain aging curve findings and preferences of health actuaries is introduced and discussed, with one representative curve presented. This curve is then measured to understand its impact vis-à-vis other curves.

It may be important to note this is not a study deriving a recommended aging curve. Rather, it is an exploration of the significance of an assumption that has not received much public actuarial scrutiny. A conclusion places the paper-s findings in a context of a dynamic health care economy in an aging society.     

Consumer-driven health care: the future is now

Given that managed care seems to have run its course, employers are forced to deal with escalating health care costs by reducing benefits and lowering pay--or are they? Why not bring the power of the responsible, informed consumer to health care? Consumer-driven health care offers a new, economically rational direction that can simultaneously address the needs of both employers and employees. This article reviews the factors leading to the need for consumer-driven health care and describes the characteristics and benefits of its current and next generations of development.     

Managed care,technology adoption,and health care: the adoption of neonatal intensive care

Managed care may influence technology diffusion in health care. This article empirically examines the relationship between HMO market share and the diffusion of neonatal intensive care units. Higher HMO market share is associated with slower adoption of mid-level units, but not with adoption of the most advanced high-level units. Opposite the common supposition that slowing technology growth will harm patients, results suggest that health outcomes for seriously ill newborns are better in higher-level units and that reduced availability of mid-level units may increase their chance of receiving care in a high-level center, so that slower mid-level growth could have benefitted patients.     

Single-payer health care systems: the roles and responsibilities of the public and private sectors

Health care systems all over the world are experiencing some change as they look for a new balance between supply and demand. This article provides context for the U.S. health care financing debate by examining the health care systems of five other countries: Canada, the United Kingdom, Australia, China and India. The authors show that, with few exceptions, countries around the world have seen an increase in both government and private health care spending between 1998 and 2002. The authors also demonstrate that employers throughout most of the world are becoming more, rather than less, involved in the funding and delivery of health care to employees and their dependents-even among nations with so-called single-payer health systems.     

Here it comes: defined contribution health care

The Patient Protection and Affordable Care Act includes provisions to make the individual health insurance marketplace one where all Americans, including those with preexisting health conditions, can obtain affordable coverage. At the same time, the act has failed to address, in any significant way, many of the underlying flaws in the current U.S. health care system that have caused costs to spiral out of control. The combination of persistent U.S. health care cost increases and a viable individual health insurance marketplace will cause a sea change in employer-sponsored health care offerings that is similar to that seen among employer-sponsored retirement benefit plans: movement away from defined benefit approaches and toward defined contribution designs. Although the authors show parallels between the evolution of employers' health care and retirement offerings, they explain why certain key developments will need to occur before defined contribution approaches become as prevalent in employer-sponsored health care plans as they are in today's employer-sponsored retirement plans.     

Health care reform: universal access is feasible and necessary

While other industrial nations' health care systems have their own problems, they have more leeway to address those problems than does the United States, which spends twice as much on per capita health care as the average for other industrial capitalist democracies yet ranks average or below average in many comparative measures of health care quality. In fact, the authors of this article argue that international experience shows that assurance of universal access through expanded government involvement could provide savings while actually improving the quality of U.S. health care. In addition, universal access would recognize health care as a basic human right, not a commodity to be bartered in the marketplace and allocated based on class, race and social position.     

Ethical values: the real crisis in health care

This author argues that the growth of apathy and greed and loss of ethical values in the current health care delivery system is due to the change in the foundation of the expectations between the consumer and the provider of health care. The agendas of the "third parties" involved with the provision of health care has caused confusion in the mind of the consumer and loss of autonomy for the health care provider. A historical perspective is provided that includes discussion of the issues of culpability for the current outcomes. Finally, the author discusses possible remedies to the current system.     

Let's put consumers in charge of health care

Businesses spend billions on health insurance. And what do they get for their money? A lot of unhappy employees. Workers fret about the quality of the care they receive, the burden of their out-of-pocket expenses, and the gaps in their coverage. For businesses, health care has become a lose-lose proposition: They pay way too much, and they get way too little. The problem is that the health care industry has been shielded from consumer pressure--by employers, insurers, and the government. As a result, costs have exploded even as choices have narrowed. But if companies embrace a new model of health coverage--one that places control over both costs and care directly into the hands of employees--the competitive forces that spur productivity and innovation in consumer markets can be loosed upon the inefficient, tradition-bound health care system. Moving to consumer-driven health care requires that companies revamp their health benefits in six ways: Give employees incentives to shop intelligently; offer a real choice of insurance plans; charge employees prices that accurately reflect the company's costs; let providers set their own prices; adjust payments for each enrollee based on need; and provide relevant information. Putting consumers in charge of health care may seem like a radical approach. But individuals are highly motivated to educate themselves about their health, their insurance, and their care, and they want to seek the most value for their money. Promoting that economic dynamic--the same that fuels consumer markets everywhere--is the best way to enhance the health care industry's productivity and quality.     

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.     

reDefined contribution health care

To combat rising health care costs and a society increasingly unsatisfied with employer-sponsored health care services, reDefined Contribution Health Care suggests a process to create a more consumer-driven health care market. To create this value-sensitive market requires a planned, staged approach that will include immediate actions and work toward fundamental, long-term changes.     

The learning curve and the health care industry

This article will examine the learning curve and its potential impact on the health care industry. Although the learning curve has traditionally been applied to the manufacturing industry, a labor-intensive industry like health care is a prime candidate for the benefits of the learning curve. Specifically, we will look at past research on the learning curve and discuss what effects learning might have on health care costs and outcomes in the current health care environment.     

How to solve the cost crisis in health care

U.S. health care costs currently exceed 17% of GDP and continue to rise. One fundamental reason that providers are unable to reverse the trend is that they don't understand what it costs to deliver patient care or how those costs compare with outcomes. To put it bluntly, few health care providers measure the actual costs for treating a given patient with a given medical condition over a full cycle of care, or compare the costs they incur with the outcomes they achieve. What isn't measured cannot be managed or improved, and this is all too true in health care, where poor costing systems mean that effective and efficient providers go unrewarded, and inefficient ones have little incentive to improve. But all this can be remedied by exploring the concept of value in health care and carefully measuring costs. This article describes a new way to analyze costs that uses patients and their conditions--not organizational units or narrow diagnostic treatment groups--as the fundamental unit of analysis for measuring costs and outcomes. The new approach, called time-driven activity-cased costing, is currently being implemented in pilots at the Head and Neck Center at MD Anderson, the Cleft Lip and Palate Program at Children's Hospital in Boston, and units performing knee replacements at Sch?n Klinik in Germany and Brigham & Women's Hospital in Boston. As providers and payors better understand costs, they will be positioned to achieve a true "bending of the cost curve" from within the system, not in response to top-down mandates. Accurate costing also unlocks a whole cascade of opportunities, such as process improvement, better organization of care, and new reimbursement approaches that will accelerate the pace of innovation and value creation.     

Health care reform and reform for health: creating a health system for communities in the 21st century

If we are to improve the health of the population and reduce the inequalities in health that plague our communities and our planet, we will have to give greater attention to the determinants of health. The reform of the health care system, necessary though it is, will never be sufficient; we need to reform our whole society and in particular to focus on human rather than economic development. At the community level we need to create healthy communities that are “health-creating systems” of environmental, social and human development, as well as health care systems that focus first on improving and maintaining health. Such a “bottom-down” health care system would see the hospital become once again the place of last resort (but still a potentially important partner in creating healthier communities) and would focus instead on how to provide health promotion and health care from the household level up.