ABSTRACT
Many within the industry believe that managed care eliminates the fraud problem. This chapter seeks to test that hypothesis and to clarify the impacts that managed care will have on opportunities for fraud and on methods for fraud control. The National Health Care Anti-Fraud Association (NHCAA) commissioned a task force to examine managed health care and to address the hypothesis that the structure of managed-care plans eliminates the opportunity for fraud. The NHCAA report on fraud under managed care pointed out the need for investigators to acquire skills in interpreting complex contractual arrangements. The attractiveness of managed-care plans for beneficiaries stems from inclusion of the extra services, a minimal paperwork burden, and small or no out-of-pocket expenses. Preferred Provider Organizations (PPO) are basically fee-for-service organizations, with incentives for the beneficiary to stay within a defined pool of providers. An Exclusive Provider Organizations is the same as a PPO, but with tougher restrictions on out-of-network services.
