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Largest Joint HHS , DOJ Takedown

Charge 301 Individuals in $900 Million Healthcare Fraud ‘Sweep’, Doctors, Nurses Among Those Arrested in Largest Joint HHS, DOJ ‘Takedown’ to Date

… Some experts say there are also measures that healthcare entities and private insurers can take in the effort to fight healthcare fraud. “Proven processes conducted by internal and external teams can occasionally catch a greedy fraudster,” says Mark Dill, principal consultant at consulting firm tw-Security. “In a larger organization, fraud detection tools are often needed to automate otherwise labor-intensive processes,” he says. “Leading tools in this space seem to have a good track record, across multiple sectors including healthcare.”

However, an organization is not likely to detect fraud if they are not looking, he notes. “Organizations need to consider which material business/clinical processes are worth – from a financial perspective – monitoring and auditing, given their limited resources. Good processes and tools are important, but keep in mind, an alert workforce with a ‘see something, say something’ awareness level/culture can often detect as many anomalies as those established processes and tools.”

Healthcare entities and private insurers can also potentially learn from the federal takedown, Dill adds.

“Fraudsters tend to repeat behavior patterns – physical and digital – that either match patterns that are known or they are new and are designed to evade common detection. DOJ and HHS should incorporate their findings into their processes and tools to better prevent and detect this type of fraud in the future,” he says. “As details become public, healthcare entities can incorporate these same tactics and tools into their own practices. If HHS is using commercial tools, the vendors may incorporate the detection patterns into their core toolsets so that all customers can benefit from this investigation.”


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