Health care is an integral part of critical infrastructure (CI). In the developed world it is the largest public cash dispensing sector. In North America, ten times that of national defense. Delivery of health care services is an extraordinarily complex system. There is no reducing financial harms in trusted diagnosing and billing environments without the cooperation of diagnosing physicians and other regulated professionals. This is an entirely different world than the hyperbole around investigation and prosecution of criminal predation. There needs to be a Chinese wall between the two, in both hyperbole and deed.
The Organization of Economic-Cooperation (OECD) predicts spending on health as a share of GDP increased significantly since 2020. Preliminary health spending estimates for a group of 16 countries suggest that per capita health increased by around 4.9% (OECD Health Statistics 2021). The United States already spends in excess of 16.8% of GDP on health care pre-COVID. Canada reports 12.7 % of GDP. Australia appears to be in a similar situation at 16.7% of GDP while New Zealand and some other European Union nations are in the 9 - 11% range.
With world population growth and global warming, it is not unreasonable to predict that COVID is only the latest and not the last pandemic. What appears to be happening, is a change to frequency.
The Organization of Economic-Cooperation (OECD) predicts spending on health as a share of GDP increased significantly since 2020. Preliminary health spending estimates for a group of 16 countries suggest that per capita health increased by around 4.9% (OECD Health Statistics 2021). The United States already spends in excess of 16.8% of GDP on health care pre-COVID. Canada reports 12.7 % of GDP. Australia appears to be in a similar situation at 16.7% of GDP while New Zealand and some other European Union nations are in the 9 - 11% range.
With world population growth and global warming, it is not unreasonable to predict that COVID is only the latest and not the last pandemic. What appears to be happening, is a change to frequency.
Insider Billing Controls
Insider billing agents are the backbone of quality health care service delivery in trust based systems. Capacity to police misuse and abuse is more in the hands of these systems' diagnosing physicians, other regulated professionals, hospitals and other treatment centers; than in the hands of plan administrators.
Health care is the ultimate trust-based system. It is hard to imagine a viable alternative. Thus, not only must insider billing audit and controls in these trust-based systems be just and fair, they must be perceived and felt (psych: affect) to be just and fair. This world of nonlinearity is complicated. How billing integrity verification and audits are framed, undertaken and escalated has a huge impact.
Plan administrators must decide whether it is important to win every battle against nature and human fallibility, or to loose the war against misuse, abuse and predatory harms.
the ATRiM Group thinks about controls from science based perspectives. Some insights, among others:
There is little empirical evidence to support hyperbole that current controls are preventing or reducing the financial harms from misuse, abuse and predation. Applying nuggets from behavioral biology and other disciplines of science, although far more complex and challenging to implement and to maintain, is predictably more effective than linear adherence at the alter of regulations, policy and guidelines.
Health care is the ultimate trust-based system. It is hard to imagine a viable alternative. Thus, not only must insider billing audit and controls in these trust-based systems be just and fair, they must be perceived and felt (psych: affect) to be just and fair. This world of nonlinearity is complicated. How billing integrity verification and audits are framed, undertaken and escalated has a huge impact.
Plan administrators must decide whether it is important to win every battle against nature and human fallibility, or to loose the war against misuse, abuse and predatory harms.
the ATRiM Group thinks about controls from science based perspectives. Some insights, among others:
- Biologists posit everything in nature cheats a little bit, right down to cell division. It is part of the story of evolution in gaining competitive advantage;
- Social psychologist/behavioral economist determined through research that when people think others are cheating, their cheating tends to increase, and when one is reminded of their morality close to the time of the temptation, cheating decreases;
- when psychological resilience is depleted, it is harder for people to resist temptations
- the farther away from face to face contact in the handling of money (ie. automated billing systems), people cheat more. In other words, without mindfulness in administering these systems in highly positive business environments, normally honest people are being set up to do bad things when tempted
- When people feel they are being unjustly or unfairly treated, it is innate to plan revenge. It becomes easier under these circumstances to rationalize bad behavior when it starts confronting their moral compass past "cheating a little bit";
- There may be, at least a partial solution. From game theory modelling, forgiving "tit for tat" (reciprocal cooperation) beats out every other cooperation model over time.
There is little empirical evidence to support hyperbole that current controls are preventing or reducing the financial harms from misuse, abuse and predation. Applying nuggets from behavioral biology and other disciplines of science, although far more complex and challenging to implement and to maintain, is predictably more effective than linear adherence at the alter of regulations, policy and guidelines.
Predatory Controls
Sometimes trusted billing insiders cross the Rubicon from cheating a little bit, to more serious activity. Some of this is avoidable with robust billing integrity strategies that apply forgiving tit for tat to the billing integrity strategy. In addition to quality control, philosophically the mindset should be to keep people from getting into trouble when tempted to do bad things.
Why are fraud and corruption horses of a completely different color?
Fraud, theft and corruption are deliberate and effortful predatory acts. This is a different game to be played by experienced investigators and prosecutors, with a direct report to the highest levels of the organization (i.e. Deputy Ministers in government systems and the Board of Directors in private systems). When these folks get involved, things can turn nasty for insiders, who are colluding with predators. To maintain trust with insiders; aggressive, punishing efforts should be supported by the vast majority of insiders and their Colleges.
How big a problem is this?
Committees’ of the United States Congress heard testimony on healthcare fraud hyperbole during the Clinton administration. The Committee took note of the hyperbole and further noted no one really knows! It is little wonder that risk managers and business decision-makers intuitively balk at putting additional resources towards “countering fraud”.
Secondly, criminologist find little correlation between myopic deterrence models based on arrest, prosecution and incarceration. Prophetically, Harvard University's Malcolm K Sparrow identified fraud rates at over 30% under specific situational circumstances. This is an important key to more effective controls. Identify and go after the outliers! Sparrow cites the problem-oriented policing services delivery as the model.
Why work with us?
the ATRiM Group is highly experienced with problem-oriented policing (POP) and situational crime prevention. Our team introduced POP to police across North America. We combine this with over thirteen years of healthcare counter-fraud/corruption research and in-house experience to developed our proprietary situational health care fraud prevention matrix and problem-solving model.
Talk to us about what we have discovered and how we go about transforming approach strategies to misuse, abuse and predatory harms.
Contact:
John Lyons at his personal email: jlyons.atrim@gmail.com, or through our CONTACT US link.
Why are fraud and corruption horses of a completely different color?
Fraud, theft and corruption are deliberate and effortful predatory acts. This is a different game to be played by experienced investigators and prosecutors, with a direct report to the highest levels of the organization (i.e. Deputy Ministers in government systems and the Board of Directors in private systems). When these folks get involved, things can turn nasty for insiders, who are colluding with predators. To maintain trust with insiders; aggressive, punishing efforts should be supported by the vast majority of insiders and their Colleges.
How big a problem is this?
Committees’ of the United States Congress heard testimony on healthcare fraud hyperbole during the Clinton administration. The Committee took note of the hyperbole and further noted no one really knows! It is little wonder that risk managers and business decision-makers intuitively balk at putting additional resources towards “countering fraud”.
Secondly, criminologist find little correlation between myopic deterrence models based on arrest, prosecution and incarceration. Prophetically, Harvard University's Malcolm K Sparrow identified fraud rates at over 30% under specific situational circumstances. This is an important key to more effective controls. Identify and go after the outliers! Sparrow cites the problem-oriented policing services delivery as the model.
Why work with us?
the ATRiM Group is highly experienced with problem-oriented policing (POP) and situational crime prevention. Our team introduced POP to police across North America. We combine this with over thirteen years of healthcare counter-fraud/corruption research and in-house experience to developed our proprietary situational health care fraud prevention matrix and problem-solving model.
Talk to us about what we have discovered and how we go about transforming approach strategies to misuse, abuse and predatory harms.
Contact:
John Lyons at his personal email: jlyons.atrim@gmail.com, or through our CONTACT US link.