Don't Just Look in the Light

Don't Just Look in the Light

Healthcare Fraud Control Articles

A pedestrian saw a man under a streetlight looking for something and asked, “Are you having any luck?”

“No,” said the man, “I’ve been looking for hours.”

The puzzled pedestrian asked, “Why are you still looking here?”

“This is where the light is.

Too often in fraud control we only look in the light. We look for patterns other people have already found. We look for patterns that are so obvious, only the most unsophisticated fraudsters would bother with them.

While were looking in the light, the fraud is going on elsewhere. How can we control where the light shines, so we can find fraud before were robbed blind?

1) Thorough review of randomly selected claims, patients and providers.

2) Use data mining and statistics to create sophisticated models that fraudsters cannot easily fool. Read a good book on data mining to find out how.

3) Follow the fraudsters who happen to walk under your light - they will take you right to other fraudsters and new patterns of fraud.

4) Think about incentives for fraud before implementing new policies. It is better not to create the incentives in the first place than to have to chase the fraudsters later.