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Politics : A US National Health Care System?
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To: Lane3 who wrote (10820)10/28/2009 10:52:48 AM
From: i-node  Read Replies (1) of 42652
 
I'm thinking like a systems analyst. It's the same notion as stopping known terrorists from entering the country rather than trying to stop them at each and every site they might bomb. It's the same notion as getting your brakes replaced rather than having to start braking twice or three times earlier each and every time you brake so you don't hit anything.

The way a systems analyst who knows about fraud prevention addresses this problem is not through enrollment. Having designed some fairly large A/P systems in my time I can tell you this. Medicare is a very large A/P system. In an A/P system you want vendors to have some qualification process, but ultimately, fraud is prevented at the transactional level. You have to qualify transactions before they make it into the payment process -- was the items properly ordered, received, etc. Medicare makes little effort in this area. And it hasn't changed materially in the 20 years or so I've been working with it.

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.

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.

The solution is in preventing the payment of fraudulent claims. That is, after all, where the crime occurs.
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