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Implement automated systems to prevent fraud

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Is healthcare fraud a significant concern for your organization? What methods does your company employ to detect fraud and abuse? Share your comments about preventing healthcare fraud, as discussed in the June 22 Healthcare IT e-newsletter.

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Different Focus for Fed. Programs

by Dilbert-Tom In reply to Implement automated syste ...

With changes due to HIPAA, and leglislated changes along with penaltys for late payments - Federal Programs like Medicare and Medicaid have invested a great deal of effort in just getting the staggering volume of claims processed and paid as quickly as reasonably possible.

Only the most blatant fraud is prosecuted (like care for dead recipients), otherwise the focus is much more on 'Who pays ?' (Fed ? State ? recipient?). I have been working with Medicare / Medicaid for several years now, and the fact is that as States face budget issues - they look to shrink IT staff and 'save on office supplies' to meet State budget shortfalls (and not much at fraud detection, prevention, and prosecution). It seems to me that a system paying hundreds of billions of dollars annually offers opportunities for IT investment to generate a great deal more benefit than it would cost to assure accuracy and identify fraud (once providers understand that these systems WILL find fraud - a lot of it would cease before it needed to be detected) if savings were, lets just say 1% - it could mean billions of dollars (so how much investment would be justified ? In millions...). But perhaps we can save a billion or two on headcount and ofice supplies instead ?

The problem is that 75% of the savings would be Federal $, being administered by State(s) - so the State's savings is only 25% of the total. Also, prosecuting Providers is politically unpopular - easier to just give away the money and consider it 'votes bought and paid for'. And recipient audits only make the State's social workers look bad, so why do that either - their job is to dish out as many as possible. And as much as possible, without embarrasing recipients (like using 'cash card' technology to pay food stamps - which are often sold at a discount to pay for smokes, booze, lottery tickets or whatever).
Meanwhile our legislators waste time reviewing stuff like RIAA's proposal to prevent technology that MIGHT be used to violate copyrights from being sold to 'commoners' (aka: Citizens not working for RIAA)...

y opinion anyway.

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