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Description
Fraud, waste and abuse are increasing dilemmas affecting the U.S. health care system. According to estimates by the National Healthcare Anti-Fraud Association and other concerned entities, fraud may account for as much as 10% of healthcare spending per annum. This percentage translates to approximately $220 billion per year in wasted funds, representing significant and negative economic implications for both the public and private sectors. Beyond its economic impacts, health care fraud has a broad social dimension; as the environment and nature of fraudulent activities continue to evolve, organized crime syndicates have established a foothold and, in addition, schemes have recently emerged that put patients at substantial risk of physical harm. While the problem of health care fraud has received relatively little academic attention in comparison to other domains, its monetary impacts are enormous and the dynamics of the issue are growing in their complexity; as such, further study and proposed solutions are warranted. A number of systems have been developed, and several significant collaborative efforts initiated, in an attempt to combat the problem of health care fraud. Current software tools are rules-based decision support systems, which cannot effectively identify many types of fraud. Attempts at collaboration have mainly involved law enforcement and payers; these undertakings have been somewhat successful, but limited in their effectiveness. This thesis argues that a primary factor in the ineffectiveness of current and recent solutions is the lack of involvement in collaborative exchange by patients. Using a knowledge management approach, leveraging fundamentals of the discipline and lessons learned, the current environment of health care fraud is analyzed. In particular, barriers to patient participation are studied and recommendations made for facilitating their active involvement in attacking the problem of fraud. Recommended solutions include a model for an effective distributed knowledge management system that is usable by and to all parties to health care transactions, including patients.
