Is “Stopping Medical Fraud” an Oxymoron?

Jeff Leston - Founder & President of Castlestone

Castlestone-LLC.com

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A politician can generally win some votes by promising (especially Medicare constituents) to “root out fraud, waste & corruption”.  For decades doctors (and patients) have faced fines and prison for filing false claims for payment or benefits.  Five years ago, Congress passed another of these laws, and in Congress’s just-passed Debt Deal, it increased funding for fraud control – around Covid funding, provider kickbacks, and billing.

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Each arrest of corrupt doctors makes GREAT newspaper articles.  Even the market for fraud detection is expected to rise from its current $3 billion to $30 billion by 2030.  The people want criminals to pay.

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But is fraud detection enough to root out the “corruption” inherent in American healthcare?  Perhaps the system itself is fraudulent.  Doctors spend more time worrying about correct coding than what ails the 50% of Americans now saddled with a chronic disease – a disease for which Pharma offers no solution.  Hospitals use sham reviews to rid their systems of maverick doctors whom we need now more than ever, to heal the explosion in cancer, heart disease, asthma, Alzheimer’s, and the list goes on. Prices are opaque and middlemen are grifting their share from corporate kingpins who pass other laws to guarantee profits and smother competition.

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Jeff, who developed the first pattern recognition system for healthcare fraud detection in the 1990s and created and implemented the technology behind the Fighting Fraud and Protecting Senior Care Act (passed in 2018), enlightens us on both the potential and the limits of fraud detection within the current system.