Robert Gordon Orr is a retired professional ice hockey player who led the Boston Bruins and Chicago Black Hawks. He's a sports legend.
What set him apart was the completeness of his game, his mastery of defense and offense. Orr won eight consecutive Norris trophies as the league's best defenseman and two Art Ross trophies as hockey's top scorer, which is a rare achievement. I'm one of many Boston sports fans who miss his artistry.
As I study fraud scams in light of insights FierceHealthPayer: Anti-Fraud collected in exclusive interviews, I'm reminded of Bobby Orr's distinctive play. Like him, fraud investigators must command a two-way game; we can't just play good defense.
"Insurers and the federal government can no longer wait for [fraud-related] complaints to arrive because often by then there's been significant loss," Deloitte's Mike Little told FierceHealth Payer: Anti-Fraud. We need to get in front of fraud and its harbingers.
Breaking news makes this point: Montana's Health Department just started notifying 1.3 million people that their protected health information, including Social Security numbers and medical records, may have been exposed to hackers last July, according to Watchdog Wire. The state didn't discover the security breach until--read it and weep--about a month ago. Unfortunately, that's not unusual.
We can do better. It's a short hop from identity theft to fraudulent billing, so finding loopholes long after criminals have time to exploit them is a luxury the healthcare system can't afford. Prevention and early detection matter.
WellPoint's Patrick McIntyre emphasized the importance of data analytics and web research to stay ahead of fraud. "It's important to learn what fraud practices are implemented nationwide and what the new fraud schemes are," McIntyre told FierceHealthPayer: Anti-Fraud. "Criminals move on to the next fraud practice or the next fraud victim. In either case, you've got to stay on top of your game."
Recognizing the need for a strong anti-fraud offense, Kellyann Bowman, SIU manager at Seattle's Group Health Cooperative, hired a former law enforcement officer to find planwide vulnerabilities. That person constantly watches for new ways fraud may infiltrate benefits and programs.
"Keep in mind that when providers find a scam that works, they expand, they branch out, they form other companies to bill the same fraud scheme," Assistant U.S. Attorney Ted Radway told FierceHealthPayer:Anti-Fraud. "And they export the scheme geographically to other jurisdictions." So effective fraud fighting requires proactive steps against scams executed elsewhere.
One such step is engaging with law enforcement at state, local and federal levels and participating in task forces and anti-fraud informational meetings, according to Aetna's Ralph Carpenter.
In the bigger picture, another tactic may be tapping criminal knowledge more often. State and federal law enforcement regularly use insiders, cooperators and informants during investigations and at trial. A famous example is Frank Abagnale Jr., the check forger who posed as a doctor and became an FBI consultant and lecturer after imprisonment. Abagnale's story inspired the film "Catch Me If You Can," which one payer used for employee anti-fraud training.
Though misdirected, Abagnale's intensity reminds me of what former Montreal Canadiens goaltender Ken Dryden said of Bobby Orr: "When he began to move ... all the Canadiens began backpedaling in a small panic, like beachgoers sighting a coming monster wave. He brought others with him, he wanted them involved. That's what made him so different: It felt like a five-player stampede moving toward you--and at his pace. He pushed his teammates ... to be better than ... [they'd] ever been."
What if we could make criminals retreat by motivating stakeholders to move together like a killer hockey line against fraud?
A famous photograph shows Orr sprawled horizontally in midair with his arms raised in the goal signal after scoring in overtime to win the Stanley Cup. Orr was tripped on the play, but he got the job done.
Fraud fighters get tripped, too, and criminals can check us hard. But there are big goals waiting to be scored for program integrity. We need to move faster to turn the game to our advantage. Like Orr, we must commit, play hard and fly. - Jane (@HealthPayer)