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.     

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.     

Fiduciaries--HMOs--incentives to ration care. Pegram v. Herdrich

Pegram v. Herdrich, ___ U.S. ___, 120 S. Ct. 2143 (June 12, 2000): An HMO cannot be liable for breach of fiduciary duty because of mixed eligibility decisions by its doctors, even if the HMO gives the doctors financial incentives to minimize care because treatment decisions made by an HMO through its physician employees are not fiduciary acts within the meaning of ERISA. Where eligibility for benefits depends upon decisions by doctors concerning their conclusions about when to use diagnostic tests, when to authorize consultations or make referrals, proper standards of care, whether a proposed treatment is experimental, the reasonableness of certain treatment, and the emergency nature of a condition, such "mixed eligibility decisions" are not fiduciary acts under ERISA, and an HMO will not be treated as a fiduciary to the extent it makes such decisions through its doctors.     

媒体上市要注意哪些问题

摘自王冉 http://wang-ran.blog.sohu.com 今天下午和华谊兄弟的董事长王中军一起同另一家知名影视公司的老总聊天.在谈到华谊兄弟的未来时,中军很有底气地说:"反正我相信未来中国一定会出现市值超过50亿美元的民营娱乐公司,我觉得我们应该有希望成为那一家."     

Electronic customer care: The innovative path to e-loyalty

In this paper, the authors argue that the use of an electronic customer relationship management system (eCRM system) enables traditional ‘physical’ customer proximity to be substituted by ‘digital’ proximity, within the scope of a multi-channel approach. This method of substitution presents enormous potential for cost reduction, profit maximisation and customer loyalty. The main intention of the paper is to illustrate how electronic customer care tools can be used to create customer e-loyalty in the field of private internet banking. The knowledge is supported by findings of a questionnaire survey based on a sample of 45 bank experts involved in eCRM and private internet banking in Germany, Austria, Switzerland and the USA. This empirical study of the capability of electronic customer care technologies to enable individual customer banking relationships in the private internet banking field demonstrates the potential for customer loyalty specifically for the internet channel of distribution.     

Linking Internet strategy to high-quality, cost-effective managed care

This article describes an experimental pilot project incorporating e-commerce and the Internet into the traditional process of health benefit negotiations through the utilization of an HMO Internet auction. The timeline and process of the auction are described, with the final auction taking place during the last week of negotiations. The results reveal an efficient and effective system to augment the traditional benefit negotiation process.     

Health care fraud: a primer on the schemes and the tools to fight health care fraud

As the national debate over health care reform moves forward, one issue with which policy makers must grapple is the percentage of health care dollars lost to fraud and abuse. The General Accounting Office estimates that as much as ten percent of total health care dollars are lost to the inappropriate, and in some cases criminal, practices of health care providers. This article discusses the characteristics of the health care industry that make it particularly susceptible to abuse and then reviews the efforts by the Office of Inspector General, Department of Health and Human Services, to deter and punish those who defraud the federal health care programs.     

New approaches to the finance and delivery of health care

Radical reform of the financing of health care has emerged onto the political agenda in recent months. Any new proposals must, however, be judged in terms of their impact on the fundamental public policy objectives of efficiency, equity and choice. How do the new proposals measure up?