by Jim Hake
VP General Manager
Lodestone Solutions

Do you ever wonder if the billing addresses you send provider payments to actually end up at the provider? Are you inadvertently sending payments to an airport address or a motel in Reno, NV?

by Robert P. McGinley
VP of Detection & Recovery Services
Plan Data Management, Inc., a Trizetto Group Co
and
James McCall
VP of Fraud, Waste & Abuse Services 
The TriZetto Group

Fraud, waste and abuse continue to cast a long shadow over the U.S. healthcare system, despite the best efforts of the federal government, industry groups and individual health plans. Although sophisticated detection tools have emerged over the past 15 years to help payors identify illegal or abusive practices, few would argue that the problem is under control.

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 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.