The National Health Care Anti-Fraud Association estimates that up to 10% of the nation’s annual health care outlay may be lost to fraud and abuse and the government is by far the largest victim. The sheer size of the governments exposure to fraud within healthcare programs is of major concern because taxpayers foot the bill. The prevalence of consumer and provider fraud schemes requires ever more sophisticated tools to stem the tide ad lessen the impact of fraud on government and the taxpayer.
Consumer Fraud includes False Claims, medical identity theft and Physician shopping — where patients move between doctors to obtain multiple perscriptions.
Provider schemes often involve phantom billing and unbundling — charging separately for parts of a single procedure.
The sophisticated nature of even the most common fraud schemes requires continued vigilance and the development of tools that “dig below the surface” to monitor, detect, analyze and prevent fraud, waste and abuse.
