Horses for Courses – Different Objectives of Clinical Coding

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 […]

Processing Claims does not FWA Management make

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 […]

Blood Money – FWA in Pathology

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 […]

The human element: managing FWA post-identification

Dr Simon Peck 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, […]

The Power of Soft Power: Stopping Waste and Abuse

Dr Simon Peck In “Misconduct health insurance fraud des matter” 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 […]

Fraud – It’s obvious if you know where to look

Dr Simon Peck I have spent most of my career tracking down Fraud, Waste and Abuse in Health Insurance. Some cases have been simple, others more complex. Schemes range from simple double-billing to organised patient sharing rings of providers (provider is the industry term for doctors/hospitals) that churn patients amongst themselves or even perform unnecessary […]