Hacker News Reader

Comment by randomacct3847 | Hacker News Reader

Medicare is notorious for being rife with fraud and waste. This ring is far from the only one.

This includes mom-and-pop doctors who “upcode” certain procedure codes so that they get paid more. There’s obviously very little the govt can do to check or know. That kind of stuff happens all the time. Like I wonder if the govt is even doing basic anomaly detection on claims data to catch these things...if a ring is getting away with $1bil it makes me think no.

Also...there got to be so much opportunity to build a company around selling a DS tool to the government or insurance companies to help detect and stop medical fraud.

View on HN

> a DS tool to the government or insurance companies

Insurance companies have actual fraud departments with investigators clinging onto every hint of over-prescribing, over-billing, over-testing or repeat visit inflation.

Medicare, on the other hand, has low administrative expense that's constantly touted as some kind of incredible achievement when compared to those "bloated" private insurers.

In fact fradulent spending increase the total spend so it lowers the administrative expense.

Isnt the 80/20 rule is a disincentive for insurance companies to go after fraud?

Theoretically, a competing insurance company that reduces fraud can offer lower premiums. In reality, this is thwarted by having significant portions of the population locked up in employer provided health insurance so they can’t shop around, although the employer is sort of shopping around for them. It would be much better if everyone was dropped onto healthcare.gov.

Health insurers are among the most inept, bloated bureaucratic institutions in the United States. Even without the built in inefficiency that comes with having your program-level capability micromanaged by Congress, they suck at fraud protection and spend a lot of time on subrogation and dependent audits. Their incentive is to deny, disqualify, and delay to defer expense, preferably into the next plan year.

Medicare has some of the power of government procurement and enforcement behind it. They pay for outcomes, not procedures, which addresses many common frauds and provides a strong discouragement for unnecessary procedures. The holes are usually around equipment and prescriptions... and the issue there is a governance issue at the congressional level.

>> There’s obviously very little the govt can do to check or know

This is exactly why the government should not sponsor billion dollar projects. If they had a direct relationship between patients and medical providers and insurer and insured it would be much harder to create these sort of schemes.

Netherlands has interesting progress:

https://nltimes.nl/2016/09/14/netherlands-gives-insurers-acc...

"The idea is to help insurers lower the damage suffered by fraudulent claims, an amount of 11 million euros last year. According to Privacy Barometer, the vast majority of that damage can be attributed to fraud committed by healthcare providers or intermediaries. Patients themselves are only responsible for 1.4 million of the 11 million euros in health insurance fraud."

They do monitor for anomalies and swing deviations from routine patterns.

Ps I’m a provider.

Yes the Government is doing something. Someone I knows spouse is a federal prosecutor. She works more like a data scientist than a lawyer. Not sure how they get cases but they claim it becomes pretty obvious once you start understanding Medicare codes.

I got the impression what they were doing was in no way automated except using excel to manipulate data. Maybe the doctors they review are flagged by some other system?

My governor famously ran one!

With complexity comes opportunity.

What are the common signs of this and where should I submit a complaint if I see them? Our longtime family doctor seems to make way too much money doing what he does just giving standard health checkups to the elderly.

Reply on news.ycombinator.com