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Reflections on Fraud, Error, Waste and Abuse

  • Dr Simon Peck, AXA PPP

iFHP Fraud, Error, Waste and Abuse Expert Panel Session The third meeting of the IFHP Expert Panel was hosted by National Health Insurance Company -Daman in Abu Dhabi from 7 to 9 May. Attendees came from Australia, New Zealand, Switzerland, Zimbabwe as well as the UK and the Republic of Ireland.

The meeting was held under the “Chatham House” rule in order to facilitate a free and open exchange of ideas so I cannot report many of the specifics. However, suffice it to say this was for me the best meeting yet - every participant brought something to the table and I am certain everyone took away some valuable learnings. Even as a veteran with some 20 years experience in this field, I came away with many new ideas.

Too often fraud conference and meetings end up being discussions about data analysis. I am not denigrating analytics - I use data analysis every day to good effect, but they are only a part of the picture - data mining only works where there is a proper infrastructure in place with appropriately skilled staff to deal with the results. This meeting was nicely balanced, we had two excellent presentations from the software companies IBM and Kirontech but this was then followed by presentations and in-depth debates on many of the real-life issues faced by those working in FWA with some very open sharing of experiences both successes and failures. Subjects covered included the challenges of making a case for criminal prosecution, advice on preparing civil claims, use of regulation and communication techniques to manage provider behaviour and the often neglected but important issue of staff fraud. Management of FWA needs many different skills and that was reflected in the mix of the participants which included ex-law enforcement, clinical staff management and IT professionals.

Anyone working in Fraud knows only too well the challenges of balancing the interests of stakeholders - for example allaying concerns from management, the wishes of procurement teams and customer service staff and the brand risk . The discussion concerning this area was the most interesting for me personally and we were shown a useful tool which formally considers each of these factors as an aid to decision making.

Another difficult issue we all face, is how to quantify fraud savings. A proper fraud strategy has effects beyond the immediate recovery or claim denial but these additional benefits are hard to quantify. It is important to highlight them however as companies tend to value what they can measure. We shared some interesting ideas on how this might be achieved and in particular an model used by a tax office to quantify behaviour changes as well as the need to presented attributed and hard savings separately.

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