by David Jackson
Bloodhound Technologies

by Russell Streur
Director of Consulting
EDIWatch

On July 30, 1965, President Lyndon B. Johnson signed legislation creating Medicare and Medicaid under Titles XVIII and XIX of the Social Security Act. Medicare was established in response to the specific medical care needs of the elderly (with coverage for extended to some people with disabilities in 1973) and Medicaid was established to provide help with the costs of medical care for those on assistance benefits. Critics warned that scam artists, crooked providers and criminal rings would rob the healthcare programs blind. The critics were right. Almost immediately, newspaper exposes and congressional hearings uncovered numerous instances of fraud and abuse within the programs. Government audits described lax oversight and called for increased efforts to detect and prevent the waste.

by Jim Hake
Vice President
Lodestone Solutions, LLC

As all of us go about our efforts to combat fraud, waste, and abuse, we need to look how current tools can be linked together to provide an impact greater than just a sum of the parts. What does our inventory of tools look like? We have clinical editing packages, fraud and abuse software packages, prospective and retrospective approaches, state license files, malpractice files, criminal files, sanction files, bankruptcy, lien, and judgment files, high risk address files, special investigative units, and law enforcement. So why are we still dealing with $170 billion in healthcare fraud, waste, abuse, and error?