ABSTRACT
The possible magnitude of health care fraud and abuse (F&A) staggers the imagination. Health policy experts provide an estimate for waste, fraud, and abuse of health care spending. The next generation waste, fraud, and abuse solution for health care needs to be implemented for the entire health insurance market. The Centers for Medicare and Medicaid Services (CMS) can and should lead the way with Medicare and Medicaid, but the best solution involves all health insurance companies working together. The current approach—using edits on a post-payment basis—catches policy errors and not fraud-rings or providers or consumers who are exploiting the health care system for their own gain. The ideal prevention system needs to be transaction-based and assesses claims on a real-time basis and before a payment is made. The basis for moving into the 21st century requires the use of proven technology from Financial Services that can be utilized in health care for cost-effective waste, fraud, and abuse identification and prevention.
