ABSTRACT
The strategy described is most relevant under fee-for-service systems, where payment systems are driven by incoming claims, and where fraud schemes involve the submission of bogus or inflated claims. Claims-based payment systems are the principal mechanism through which criminal fraud currently bleeds the health care system. The job of stanching that flow is urgent and cannot be put off in the vague hope that managed care will one day solve the problem. Once properly registered as a supplier of services or products, fraudulent operators obtain the necessary billing software and go to work, exploring the payment systems with a variety of claims. The model fraud-control strategy begins with an emphasis on seeing clearly, which requires a commitment to systematic measurement—painful and difficult as it may be. Under a model fraud-control strategy, investment in control systems would be related in some direct and obvious way to the size of the problem, as determined by measurement.
