Health care is the most complex of critical infrastructures; spending ten times that of national defense in North America. There are similarities with United Kingdom, much of western Europe, Australia and New Zealand. Delivery of health care is unique. It is build on a trust-based provider billing system. With over a decade of consulting on insider abuse/misuse and fraud threats posed to a major Canadian health care system, we draw a fundamental distinction between billing misfeasance by trusted insiders; and the predatory nature of fraud.
Two Intersecting Solitudes
INSIDER BILLING INTEGRITY CONTROLS: Financial harms committed by trusted billing insiders begins small-scare with cheating the systems a little bit. A 'noise' left unattended to' is likely to manifest into a 'storm'. In aggregate it can be more costly than predation of the systems. Reducing defection from trust is complex. Expect some cheating. Evolution has prepared all organisms to cheat at least a little bit. It is part of the natural law for all organisms struggling to gain competitive advantage. Neuroscientist and behavioral biologist Robert Sapolsky {Stanford University, CA] makes a compelling argument that there is o such thing as 'free will'. Thus the relationship between health care administrators and trusted billing providers is critical to sustaining emotional resilience for resisting temptations with justifications or excuses.
PREDATORY FRAUD CONTROLS: Countering predation (i.e. fraud) is a horse of a far different color, that at times involves the corruption of trusted insiders. Over hyperbolic counter-fraud language and communication pointed at trusted insiders has profound implications on controlling their cheating and obtaining their cooperation in countering predation. The language and deeds to tackle fraud are not the same as the policy, language and deeds required to reduce financial harms to the payment systems from defection by trusted insider. Countering fraud is the nasty business of intelligence gathering, criminal investigations and prosecutions.
the ATRiM Group recommends placing a Chinese Wall in organizational structure, policy, words and deeds between the billing integrity payment system controls and the counter-fraud culture. This division should be both in reality and the perception of it by trusted insiders.
Two Intersecting Solitudes
INSIDER BILLING INTEGRITY CONTROLS: Financial harms committed by trusted billing insiders begins small-scare with cheating the systems a little bit. A 'noise' left unattended to' is likely to manifest into a 'storm'. In aggregate it can be more costly than predation of the systems. Reducing defection from trust is complex. Expect some cheating. Evolution has prepared all organisms to cheat at least a little bit. It is part of the natural law for all organisms struggling to gain competitive advantage. Neuroscientist and behavioral biologist Robert Sapolsky {Stanford University, CA] makes a compelling argument that there is o such thing as 'free will'. Thus the relationship between health care administrators and trusted billing providers is critical to sustaining emotional resilience for resisting temptations with justifications or excuses.
PREDATORY FRAUD CONTROLS: Countering predation (i.e. fraud) is a horse of a far different color, that at times involves the corruption of trusted insiders. Over hyperbolic counter-fraud language and communication pointed at trusted insiders has profound implications on controlling their cheating and obtaining their cooperation in countering predation. The language and deeds to tackle fraud are not the same as the policy, language and deeds required to reduce financial harms to the payment systems from defection by trusted insider. Countering fraud is the nasty business of intelligence gathering, criminal investigations and prosecutions.
the ATRiM Group recommends placing a Chinese Wall in organizational structure, policy, words and deeds between the billing integrity payment system controls and the counter-fraud culture. This division should be both in reality and the perception of it by trusted insiders.
Insider Defector Controls
Diagnosing physicians, other health care professionals and their Colleges are the backbone of high quality, trust-based health care systems. We know from game theory that 'forgiving tit for tat' outperforms every other cooperation model a the end of the day.
Our SafeGrowth prevention science practitioner partners teach us that engaged, informed citizens are more effective in reducing anti-social behavior harms than the police and courts. In the same way, trusted insiders cooperating with health care administrators, increases effectiveness in reducing financial harms to health care plans posed by trusted insiders. We know from game The mastery is in undertaking small-scale initiatives with high quality data collection and management that are situational specific enough to measure the problem going in, and to quantify the results of interventions.
Our SafeGrowth prevention science practitioner partners teach us that engaged, informed citizens are more effective in reducing anti-social behavior harms than the police and courts. In the same way, trusted insiders cooperating with health care administrators, increases effectiveness in reducing financial harms to health care plans posed by trusted insiders. We know from game The mastery is in undertaking small-scale initiatives with high quality data collection and management that are situational specific enough to measure the problem going in, and to quantify the results of interventions.
Predatory Controls
There is little empirical evidence to support that linear enforcement and prosecution reduces crime. There is ample evidence that multiple simultaneously deployed strategies to counter persistent geographic or situational specific patterns of crime can reduce crime and other forms of predatory misfeasance. Put succinctly, using a broad range approaches to inform a focused course of action produces crime reduction results.
Why work with us?
The ATRiM Group teaches and practices the problem-solving, situational crime prevention written about in Prof. Malcolm Sparrow's seminal book: "A License to Steal: How Fraud Bleeds the American Health Care System [2000]. Our trained, experienced team of prevention science practitioners will help you put the recommendations made by Prof. Sparrow into play. We will present you with our proprietary situational health care fraud prevention matrix as a guideline and train your fraud problem-solving teams. They will build on/modify this matrix from addressing your unique circumstances as they continuously learn from identifying and attacking the root causes of health care fraud hot spots and patterns.
Direct Contact for More Information:
John Lyons email: [email protected], or through our CONTACT US link on the website.