August 3rd, 2009
Scalpels against five levels of medical greed
Why does medical fraud happen and how do we stop it?
Allen DeKaye, a consultant in receivables management and medical coding based in Oceanside, NY, says he has the answer.
(Picture from the Metropolitan Chicago Healthcare Council, where DeKaye addressed a 2005 symposium on health plans)
In a Health Care Compliance Letter article published on his Web site, DeKaye identifies five levels of greed when it comes to medical fraud:
- Undisciplined greed, people sneaking into records because they themselves have no ethics.
- Opportunistic greed, a financial motive giving such people the chance to commit real fraud.
- Corporate greed, in which loopholes are exploited and theft becomes organized.
- Scheme greed, in which opportunistic or corporate greed are organized into a plan for theft.
- Organized greed, which could mean organized crime but more often involves schemes repeating themselves once they are shown to work.
Corporate greed is as likely at non-profits as for-profit hospitals, DeKaye writes, since people at these institutions are still competing for raises, promotions, and honors.
DeKaye’s proposed solutions may be as controversial as his causes seem obvious:
- Drills, in which proper procedures become habits just as in the military.
- Behavioral interviewing, which are often used in seeking leaders, can also help root out those whose ethics will lead them to prying into records.
- Background checks. They may be expensive but they can detect motives for future fraud.
- Data mining. Analysis of claim data can detect schemes, and scheme patterns, just as analysis of health records themselves can detect best practices.
- Red Flag Rules, originally crafted by the FTC against identity fraud, include collecting driver’s license, social security numbers, and credit checks to detect fraud by patients.
Essentially, DeKaye writes, health care workers are bankers, and need to be treated as such. That means they must prove their honesty, know their frauds will be uncovered and that there’s no re-entry for those who commit fraud.
Nationalizing these efforts is also important, he writes. Most schemes move with criminals from state to state, and sharing these “worst practices” can detect crimes sooner.
He concludes:
If the hierarchy of greed can help explain in some way what is inside criminal minds, then it is possible that the remedy lies in the precision of the laser beam (e.g., task forces, data mining,
and education, etc.) being trained and focused on the diseased portions of the brain (e.g., levels of greed) to remove the various lesions.
Is this the way you want health care workers treated? Is it the way you want to be treated, as a customer?
Dana Blankenhorn has been a business journalist since 1978, and has covered technology since 1982. He launched the Interactive Age Daily, the first daily coverage of the Internet to launch with a magazine, in September 1994. See his full profile and disclosure of his industry affiliations.
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| 08/03/09
