Don’t Create New Loopholes
Sometimes in health insurance, we practically give out recipes for how to get away with fraud. The key to getting away with insurance fraud is to look like everyone else. That way, you stay off the fraud detection radar screen. If we use certain indicators to measure quality (mammograms per 1000, pap smears per 1000), and we don’t do thorough audits to make sure the services were actually provided, providers know they can bill for these services for all their patients in the target population. They don’t have to provide the services, unless you’re actually checking up on them.
I’ve heard of HMOs paying for high compliance to quality goals or allowing compliant providers to avoid the normal authorization process to approve expensive services. This is like saying, follow these certain rules, then we’re going to trust you not to break any other rules.
Try to avoid making rules that are easy to abuse in ways that are hard to detect. If you know how the rules could be abused (because you’ve examined it from the fraud perpetrator’s point of view), then you can build in controls before you implement the rules.
Why don’t we evaluate the risks of new rules before we implement?
- Not my job
- Don’t know how to recognize fraud
- Nobody clearly in charge
- No clear way to report suspicions
- No feedback about what happened with a case