Are you part of the healthcare fraud problem? (Part 1)
John Maynard, CPA, CFE, AHFI
Principal Solutions Architect at SAS | Healthcare & Govt | Changing the World with Advanced Data Analytics
By John Maynard and Tim Taylor
The topic of fraud in government programs can be quite complex. Some have said there is no fraud in government programs. This position ignores that any financial system, whether a bank or social benefits program, is subject to fraud. There is no perfect mousetrap to prevent fraud. If cheese (money) exists anywhere in the world, there will be rats who do anything to get at it.
Unfortunately, government leaders that focus on compliance and safeguarding public funds often face some significant conflicts. Further, ignoring fraud puts healthcare patients and those who receive other social benefits at risk.
Seek and Ye Shall Find
When government staff become proactive about fighting fraud, they will inevitably deploy some detection methodologies. Personally, I suggest advanced analytics. This results in a list of potentially fraudulent cases (e.g., applications, benefits, loans, claims, etc.). Some will be false positives (flagged cases with no fraud). Others will be legitimate fraud once fully investigated. The problem is that the number of potentially fraudulent cases almost inevitably exceeds the number of government staff to respond to them. Unfortunately, doing the right thing in attempt to identify and fight fraud may open the government fraud team to unwanted, and often undeserved, criticism. The only thing worse than being outgunned by criminals when fighting fraud is getting attacked on you flanks by those with their own agendas that have nothing to do with stopping fraud.
Not all governments are doing their best. But, how would you feel if you were doing everything you could with the resources available to you only to get sucker punched by others for not doing enough?
No Good Deed Goes Unpunished
In government, we used to joke that no good deed goes unpunished for many reasons. Government is political by nature, and this may subject the fraud team to inflammatory allegations rendered to score political points. Likewise, news outlets love a good headline, and the concept of government waste is a good click-bait – even for me. Not only will a state auditor, auditor general, or inspector general of an opposing political party chastise government agencies and staff in reports and news releases for not finding enough fraud, we have seen this done by the same political party as people seek their next political office.
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Most governments have some form of open records. Thus, reporters may request summary reports of government fraud team operations. These may show many identified potential fraud cases, but only a few completed or proven fraud cases. Reporters have been known to use this to browbeat government fraud teams. I have seen news articles that list the large number of potential cases without pointing out many may be false positives or fraud teams lacked staff and funding to properly pursue fraud. Criminal fraud is only determined by courts, prosecutors, and juries. Government fraud teams have no control over the efforts of these entities or what is often a lengthy process. These facts are often left out of inflammatory reporting.
Fraud Costs All of Us – You Can Help
As I shared in a previous blog, “3 Reasons Fraud Costs All of Us”, healthcare fraud continues to explode. Hundreds of billions of dollars are wasted annually on fraud. Healthcare fraud increases premiums for patients, wastes tax dollars in government plans like Medicaid and Medicare, and diverts tax dollars from other needs.
2023 International Fraud Awareness Week is November 12-18. You can help by learning more about how to fight fraud. Please follow this 3-part blog series as well. SAS Institute has powerful solutions for fight fraud.
SAS Payment Integrity for Healthcare – a single platform with powerful fraud analytics to help governments succeed.
Staff Augmentation with Artificial Intelligence Can Help
Governments have trouble finding and keeping staff in healthcare fraud and beyond. AI-based technologies can help augment staff work with technology such as intelligent decisioning and text analytics. SAS Institute has solutions that can help.
SAS AI (Artificial Intelligence) and Machine learning cutting edge technology provides needed relief to staff review and assessment assignments as well as augments the decision-making process using Composite AI.