There are untold examples where misplaced trust results in the victimization of the trusting party. Look no further than “catfishing” schemes, spearfishing efforts, investment frauds, ponzi schemes and “get rich quick” schemes. All of these rely on blind faith on the part of the individual victim. It is only through blind faith in the fraudster that a victim will send thousands of dollars to “that poor soul” on the oil rig who is just trying to get home or invest their life savings in that fledgling investment fund with the impossible to believe prospectus.

These frauds largely victimize individuals – many of them elderly or otherwise not equipped to defend themselves. But what about an entire industry or government program that is also systematically victimized? How does that happen? Well, let’s look at health care as an example. 

It’s no secret that all health care plans rely on trust. With hundreds of thousands of providers and millions of claims, there must be trust that those providers are telling the truth and doing their best to be accurate when they submit those claims. There is no way that every claim can be verified before it is paid. And even a jaundiced Investigator like me has to admit that the trust is largely well placed. It is only a few that are intentionally taking advantage of that trust – but that minority have a huge impact. Just a glance at the annual HCFAC report or the bevy of DOJ press releases reflect that impact. 

But unlike individuals, health plans have defenses in place – prepay edits, program integrity arms, special investigation units – all geared to save or recover funds. Despite these efforts and the resources needed to fund them, the losses to fraud, waste and abuse are monumental. Why? 

The answer is simple. No amount of program integrity work will eliminate fraud, waste and abuse within a fee-for-service system.  This system is based on trust and, as we have seen, the small percentage of providers that take advantage of that trust force the insurance plans and government program agencies to take more and more steps to protect the plans and its members. While somewhat effective these efforts also increase fraud, waste and abuse losses by creating ever-more complex and confusing regulations and incentivizing provider bad behavior by increasing their administrative costs (billing company services, compliance plans, legal costs, etc.). Those provider costs must be offset and the easiest way is to increase the fee-for-service billing. 

So, what is the solution? In today’s health care paradigm, there is no solution. A system based on a  fee-for-service model where trust in the honesty of every provider to know how and do the right thing is inherently flawed. This paradigm is too ingrained to try to change it in short order. It will take a shift in the fundamental foundation of health care in this country to make the changes necessary.  Absent that, we must find better program integrity methods.  

Collaboration between plans rather than competition, regulatory simplicity rather than byzantine and conflicting policies, reimbursement based on quality rather than quantity of services are some avenues to consider. Advize is ready willing and able to help in these and any other ways to improve the health care system in this country.