May 16, 2014 | Written by: Paul Dommel
Health care fraud costs governments hundreds of billions of dollars each year. Being a nut about effective government keeps me thinking about waste, fraud, and abuse. Fortunately, things are looking up.
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In mid-May, the US Medicare Fraud Strike Force charged 90 people with defrauding Medicare of $260M. Some charged were physicians receiving kickbacks for referring patients to medical equipment suppliers. Many didn’t need any equipment at all. Others were providers who submitted bills for patients they never saw and whose patient information was obtained illegally.
WSJ: Task Force Accuses 90 of Bilking Medicare
The Strike Force has worked in 9 cities since 2007. It has identified nearly 2000 providers who have billed $6 billion to Medicare. Last October, the GAO estimated the Health Care Fraud and Abuse Control Program returns $7.90 for every $1 invested. The Strike Force operates under this program. $8 for $1 is an amazing ROI, but consistent with other studies showing phenomenal returns on investigation into healthcare fraud.
IBM works with insurance companies and governments to help our clients to identify and root out fraud and error. We just launched a Smart Counter Fraud initiative to increase our focus on this space. We have great approaches to identify suspicious activity. We use other techniques to expand investigations from a simple focus on individual providers into the nefarious networks in which they operate. IBM solutions help clients to identify those who create aliases and shell companies to hide their activities. Our technology is infused with insights from an active community of investigators around the globe.
Healthcare fraud is big business. Like other businesses, fraudsters have strategies and those strategies evolve over time. They are constantly looking for an edge. They have networks of relationships and share lessons learned. Some evolve from street gangs, others are part of global networks. The organizations, approaches, and technologies to investigate and deter fraud must constantly evolve.
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Like the S.H.I.E.L.D. team in the Iron Man movies, the Strike Force is protecting the system and scoring some victories. So, kudos to the Medicare Fraud Strike Force operating under the Health Care Fraud and Abuse Control program. Just one thought — you might consider a cooler name.
Click on this link learn more about IBM Smarter Counter Fraud Solutions. IBM Smarter Counter Fraud