On the enrollment front the process doesn't need to be more difficult it needs to be more effective. But that will NOT stop fraud or make a significant dent in it. I don't know of anything you can do with the enrollment process to solve this problem.
If you can stop one bogus enrollment you have stopped thousands of frauds. That is more cost effective, in principle. Of course you'd have to work through the feasibility and costs of stopping that enrollment vs stopping thousands of frauds, but it's sure worth focusing on at least until you prove that stopping an enrollment is impossible or too costly.
Assume I'm an enrollment specialist at Medicare. How do I distinguish between a provider who is going to bilk Medicare out of money next money and one who isn't? The answer, of course, is that I don't and I can't.
You know more about Medicare enrollment than I do. I am working off the 60 Minutes story. The story focused on cases where parties who had no business operation were enrolled. That is low hanging fruit. Sure, you're not going to stop the doctor who makes a fraudulent claim for every twenty of legitimate ones that way. But you sure can stop medical equipment companies that don't exist. That is certainly feasible.
Having designed some fairly large A/P systems in my time
Then you know that you have two entities, the enrollee and the claim. You have a data set surrounding each. There are thousands of claims transactions, maybe millions, per enrollee. Fraud is possible at both levels. You can have fraudulent enrollees and fraudulent claims. The enrollee is the bigger fish. It's foolish to dismiss the big fish.
The solution is in preventing the payment of fraudulent claims. That is, after all, where the crime occurs.
Stop the criminal and you have effectively stopped the crimes. It's as simple and essential a crime-stopping technique as putting a lock on your door rather than putting a lock on your TV, computer, and jewelry. If you don't have an impenetrable door lock, want your kleptomaniac friends to keep visiting you, or are dotty and sometimes forget to lock your door, then you can lock your individual stuff as well, but you still keep a lock on the door. |
