For years significant resources have reportedly been directed towards combating health care fraud by insurers, regulators, law enforcers and legislators. Yet, despite these reported efforts, it would appear, based on the annual estimates, the problem continues to grow and flourish. Could this indicate that health care fraud is at epidemic proportions and can’t be stopped as our health care system is infested with health care providers who will stop at nothing to make a buck? I think not.


My experience, over two decades of working with insurers, law enforcers, regulators and health care providers, suggests that most health care providers are honest, ethical and strive to do the right thing! Additionally, my experience has provided me with the opportunity to see the fraud problem from both sides, that of enforcement and the provider. When viewed from both perspectives, it is readily apparent that our health care fraud problem is caused by a number of factors, including:


1. Inadequate education for health care providers relative to coding and payer standards.


2. Deviant providers.


3. Inadequate training for claims handlers and claims investigators on coding and provider standards.


4. Inept claims handling and claims investigations by insurers prior to paying claims.


5. Lack of communication from insurer to provider on what is required.


6. Paucity of reliable training for law enforcers regarding the investigation of health care fraud – from identification to prosecution.


7. Tag-a-long investigators looking for organizational stats resulting in the inefficient use of law enforcement resources.


8. Lack of interest or commitment by prosecutors – big cases big problems, little cases little problems.


9. Lack of accountability for all segments of the health care delivery system – provider, payer, regulator and enforcer.


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