Are you part of the healthcare fraud problem? (Part 3)

By John Maynard and Tim Taylor

The topic of fraud in government programs can be quite complex. Let’s continuing from our discussion in Part 2. Governments that try to fight fraud sometimes face less than encouragement. When we look away from fraud, either from fear or even political view, we open the door to real atrocities.

When Doctors Go Bad

In healthcare, we have seen providers purposely misdiagnose patients to provide medically unnecessary treatment. This may range from dentists destroying healthy teeth to then repair these same teeth with high-cost reconstructions to oncologists giving healthy patients high doses of expensive chemotherapy. This harms patients, if not kills them, and should never occur. If governments do not seek out and remove these fraudsters, then we argue they are complicit in both the crime of health care fraud and in allowing these providers to harm patients. Only fraudsters benefit from this pattern.

Healthcare and Social Benefits Fraud Harms Beneficiaries

Outside of healthcare, ignoring beneficiary fraud signals may ignore other existing risks of harm. Dealing with problems when they reach a critical stage is always more costly for government, especially when cost-saving preventive measures were available. Abusing government social benefit programs may be a symptom of underlying substance use disorder, abusive families, elder abuse, and more. The eventual result may be senior citizens being hospitalized or displaced from their homes, family crisis and homelessness, child welfare interventions, or worse. Fighting fraud can uncover other issues and allow governments to take lower cost interventions that are more likely to lead to better beneficiary outcomes while keeping safer at-risk populations like seniors, children, the disabled, and those with substance use disorder. Ignoring fraud signals enables fraud and puts people at risk.

Fraudster Commit Other Crimes Against Their Prey

Sometimes bad actors force beneficiaries into abuse and fraud of government programs under duress. We have seen this with elderly beneficiaries that were being subjected to physical/mental abuse and neglect. Far worse is when a fraud ring twists an entire community of beneficiaries into potential fraud. We have seen this occur in refugee communities where gangs force community members to apply for various benefits and give those benefits to the gang. Here, the gang controls, by threat and actual violence, both the local beneficiaries, their families, and family members back in the country of origin. Only fraudsters benefit from this pattern.

If we don’t say no to fraud, we are saying yes. Fraud is never okay – it hurts real people in many ways. When governments ignore fraud, we become part of the problem rather than part of the solution. We can do better.

2023 International Fraud Awareness Week is November 12-18. You can help by learning more about how to fight fraud. Thank you for following this 3-part blog series as well. SAS Institute has powerful solutions for fight fraud.

Finding a single tool that can monitor transactions and identify possible fraudulent activity could be thought of as unrealistic expectations, but SAS Fraud Management can do just that. It easily integrates and houses data from all sources on a single platform. Having a tool that can monitor and risk score on demand in real time helps staff take the guess work out. Using advanced analytics and generating easy to read dashboards and reports gives government agencies everything they need to make a stand against fraudsters.