Healthcare Fraud’s Big Business
Medcaid fraud is big business. Criminals are ripping off the system and its costing taxpayers billions of dollars annually.
Recognizing the serious flaws in the system, which are being exploited by providers and organized crime rings, the federal government’s expressed a willingness over the last couple years to “get after it” from a fraud detection, investigations, enforcement and prosecution standpoint. Clearly, that’s the right thing to do.
As a result, there have been increased numbers of investigations, prosecutions and convictions of players in the healthcare fraud arena.
We’re not nearly where we need to be with this effort yet but it’s definitely a step in the right direction.
Healthcare Fraud Detection
Correspondingly, while healthcare fraud’s big business, private sector healthcare fraud detection, and analytics, is also big business. The critical emphasis is on fraud detection tools which analyze large blocks of “big data” to pinpoint the red flags of fraud.
The major players in the fraud detection, analytics and investigations space all have assorted anti-fraud offerings which are marketed to federal and state governments around the country.
One of the keys to effective fraud detection/prevention is analyzing “real-time” information for decisioning vs. flagging historical claims data after the fact when the horses are already out of the stable.
21CT’s In The News
When indictments, arrests, prosecutions and convictions of healthcare fraud suspects occur it’s news and the media’s littered with those stories.
Currently, however, there’s a different kind of legal saga unfolding in Austin, TX. At issue, a $110,000,000, “no bid” Medicaid fraud detection contract previously awarded to Austin based 21CT by the State of Texas and other industry players are crying foul over the process!
The genesis: information provided to the American-Statesman about the government contract process lead them to conduct a “deep-dive” into the circumstances behind how the fraud detection contract was awarded.
During their underwater exploration, the Statesman not only dove into this contract but the Texas “no bid” contracting process, the government players involved and the relationships between those individuals and the ultimate contract recipient: 21CT.
In case, you haven’t seen the extensive news stories that have been written about it, here’s a chronology of critical dates, events and the links to their stories as reported by various news media outlets:
12.12.15: State’s Top Lawyer Resigns
12.17.15: Second 21CT “No Bid” Contract Cancelled
12.19.15: IG Fired – 3 Others Put On Paid Leave
12.22.15: 21CT Sues Former Lobbyist
12.29.15: 21CT Laying Off Employees
01.03.15: Political Donations Preceded Contract?
01.14.15: FBI’s Involved?
01.21.15: Lobbyist Fires Back At Company
01.22.15: Who Are The Investors?
01.22.15: CEO: “No Investors”
The Last Word
This story’s turned into quite an epic drama and the industry’s watching with interest to see how it plays out. Information reported suggests that investigations are underway. While several agencies have confirmed they’re looking, the FBI’s position is that they “neither confirm nor deny” the existence of ongoing investigations.
At this point, nothings been reported about any criminal charges so we’re in a “wait and see” mode while investigations are ongoing to determine if any are forthcoming. Meanwhile, let’s remember that everyone’s “presumed innocent” until proven guilty in a court of law.
Those are our insights. What are yours?
For more information on how we can help your businesses prevent risk, reduce major fraud losses and improve operational ROI, contact us to schedule an initial consultation. No obligations…just unique insights from an industry leader.