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Lights, Camera…Fight Fraud in Health Care

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There was speculation that the Health Care Summit hosted by President Obama would be a Kabuki Dance or a highly staged photo opportunity. Instead, the seven- hour event ended up being a good forum for debate. There was no “Minnesota Nice” as both sides openly expressed their views on health reform. While there were some long-winded anecdotes, many of the attendees focused on having a data-driven discussion. Most importantly, the cameras offered some clues on how nonsensical and expensive provisions get incorporated into legislation.

Republican Senator Tom Coburn, a physician, started off strong when he boldly stated that the nation needs to address the escalating costs of health care before expanding access to 30 million additional Americans. He raised the issue of rampant fraud in the system, estimated to cost the $60 billion a year in Medicare alone.

But, his comments took a bad turn when he said, “In your new bill, you have good fraud programs, but you lack the biggest thing to do. The biggest thing on fraud is to have undercover patients so that people know we’re checking on whether or not this is a legitimate bill.”

Obama scribbled some notes, and subsequent news reports highlighted Coburn’s idea as one of the few common areas of agreement. In the President’s follow up letter to Congressional leaders on March 2, he included undercover patients as one of four good ideas that he is willing to integrate into his plan.

Deploying "mystery shoppers" may be useful in highly targeted situations when a thief must be caught red-handed for a quick prosecution. Otherwise, this is an archaic and expensive approach for identifying fraud. Unless there is blatant illegal activity, such as billing for a deceased patient or billing for tests and visits never performed, it requires multiple visits to prove that unnecessary or inappropriate services are repeatedly and systematically rendered.

This approach is neither scalable nor efficient. Organizing a field force of hundreds of secret shoppers would certainly result in yet another department within HHS with its own separate budget.

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We value and respect our HERWriters' experiences, but everyone is different. Many of our writers are speaking from personal experience, and what's worked for them may not work for you. Their articles are not a substitute for medical advice, although we hope you can gain knowledge from their insight.

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