Dr Simon Peck At a recent meeting, one of our clients said that many people do not understand the difference between Claims Processing and FWA (Fraud Waste and Abuse) management. We thought the distinction between the two would be an interesting subject for this bulletin. Let me start by illustrating this with a couple of case studies from my own…
Dr Simon Peck In his book “Profiles of the Future: An Inquiry into the Limits of the Possible”, Arthur C. Clarke made the following, widely quoted observation: “Any sufficiently advanced technology is indistinguishable from magic”. In today’s world, there are many kinds of advanced technologies ranging from nuclear fission to computer chips. One area that continues to fascinate is medicine…
Dr Simon Peck In https://www.linkedin.com/pulse/misconduct-health-insurance-fraud-does-matter-kirontech-uk-ltd/ we discussed the differences between various kinds of FWA (Fraud Waste and Abuse) in Health Insurance. We looked at three case studies – one involving criminal conduct (Patterson) and two others where there was misconduct but no crime. We noted that from a legal perspective, the distinction between criminal and non-criminal is important. It matters both for…
In our previous bulletins, we discussed in some detail the identification of Fraud, Waste and Abuse (FWA) in health insurance claims. When identifying FWA, challenges are mostly technical and related to data quality, processes and analytic capabilities. After FWA has been identified, the game changes. We are met with a different challenge, one that has very little to do with…
Dr Simon Peck In his classic book “License to Steal – how Fraud Bleeds America’s Health Care System” Malcolm Sparrow observed that in the hands of those who would steal there are few commodities as valuable as a vial of blood. He is certainly right about that – pathology and blood tests are a huge source of Fraud, Waste and…
Dr Simon Peck One of the primary uses of Kirontech software is to identify unusual patterns of behaviour in healthcare claims. When looked at individually, most claims look perfectly normal. It is only when we analyse at large groups of claims over time that we begin to see patterns of behaviour. By using traditional rule-based methods that often focus on…