Tackling healthcare fraud: the uncontrollable beast or the example of good practice?

Jul 7, 2023Webinars and Blogs

Healthcare fraud is a massive problem, the scale of which is only best guessed at, the FBI estimates ‘tens of billions of dollars’, are lost annually in the US, in England alone the government estimates well over a £1 billion was lost last year. The word ‘fraud’ in fact disguises a wide range of criminal acts that vary greatly involving staff (sometimes working with third parties) including GPs and other professionals, contractors, patients and others. The losers are the public. Meanwhile, state sector resources around the world are limited while there is a burgeoning private sector that is often marginalised. So what can we do? What are the key challenges and how are they being approached? What is the role of the private sector and is it being appropriately engaged for the public good? This webinar will discuss: The threat posed by the different dimensions of healthcare fraud The vulnerabilities and how they are being responded to The opportunities in the private sector and how to maximise them for public benefit.

Chair: Dr Janice Goldstraw-White

Alex Rothwell – CEO, NHS Counter Fraud Authority
Louis Saccoccio – CEO, National Health Care Anti-Fraud Association (US)
Nicole McLaughlin – Counter Fraud Specialist, Guy’s and St Thomas’​ NHS Foundation Trust

Key Points
Alex Rothwell opens by posing the question of whether healthcare fraud is an uncontrollable beast or an example of good practice stating that he thinks it is both. He notes that a person is more likely to be a victim of fraud than of any other crime and that this is increasing year-on-year. Although he acknowledges that this enables us to get a better understanding of fraud issues, he feels it is a widening threat surface, especially with increasing use of technology which enables fraud. However, Alex thinks there is always a choice – maybe not always for victims – but certainly for governments, regulators, policy-makers, business owners and even their decision makers. He believes that there is a choice about how tolerant we want to be about fraud, what controls are put in place, the speed of decisions, and how uncomfortable we can make the environment for fraudsters. When considering how good we are at tackling public sector healthcare fraud in the UK, Alex recognises it could be better, but he feels generally in the healthcare sector we have a mature function, in fact he points out the NHS has had a response to fraud for at least 30 years, whereas some other government departments are just realising (especially in light of Brexit and the Covid Pandemic), that their fraud response is inadequate. The NHS has a framework to work to and intelligence capability, as well as a lot of collective knowledge of the system. Therefore, Alex feels that they can hopefully continue to improve on this, which will result in more money available for patient care.

You will hear Louis Saccoccio outline that because of the way that healthcare is paid for in the US (consisting of Medicare, Medicaid and private insurance – a good proportion of which is funded by employers), that private and public partnerships are important. He states because of this mix of payers, it has always been critical to bring the health insurers (public and private) together and involve others, such as the FBI, Department of Justice, Inspector General’s Office, Department of Health and Human Services to do what they believe is the critical thing – to share information. He believes that you can’t tackle fraud in silo, you have to understand the bigger picture. Louis outlined the increasing importance of data analytics to identify what frauds are out there are and that this is now being seen more in the US both on the federal/state and private side. He emphasised that you cannot do this type of work without being on the cutting edge of data analytics and that you need to catch fraud before it happens and try not to get into a ‘pay and chase’ situation. Louis concludes by raising the issue of resources for anti-fraud work, pointing out that healthcare spend in the US represents almost 20% of their gross national product, and to give a sense of the level of fraud in the system, he notes that The Journal of the American Medical Association (JAMA) conducted a study in 2019, and found that fraud for Medicare alone was estimated to be between $55-83 billion, leaving a question about how to resource anti-fraud measures in this area.

We hear from Nicole McLaughlin that she believes the main challenge with the NHS at the moment, similar to what Louis said, is resources, both financial and recruiting and retaining staff. She outlines how this is against a backdrop where the NHS is offering many types of health care, to a growing population with increasing health needs, most of which are funded by the government, while at the same time staff are feeling undervalued and want a better work-life balance as evidenced by recent strike action. She believes that the private sector see huge opportunities to help the NHS, but also opportunities to make a profit for themselves, pointing out that she thinks that what they offer is often good, but badly thought out and often lacks engagement. Nicole points out that the NHS is a very complicated system – sometimes even more than it needs to be – and that the private sector have a lack of understanding about this and have a tendency to come in with short term solutions or a ‘quick fix’, often focused on digital solutions, but she feels that this is not always predominantly what is needed and often forgets the people element. Nicole believes the main challenges for the private sector is to have more long term planning and possibly see helping the NHS as a more charitable venture and have more social responsibility. In terms of their focus on fraud, she feels that many in the private sector are reluctant to get involved because there is not enough money in it and it is often difficult for both public and private sectors to throw more money into fraud after they have lost money to fraud. Whereas, she believes the private sector can offer so much more than the public sector, especially in innovation and technical ability, they need to understand how the NHS can use and afford to use that.

This webinar has highlighted the current issues for the healthcare sector when tackling fraud under modern day pressures. Increased demand for services against limited financial resources and a workforce that is difficult to recruit and retain are seen as some of the main challenges. In the US, possibly due to the nature of how healthcare is funded and the various public and private parties involved in this, partnership working has always been essential and has generally worked well. Whereas in the UK, where the majority of healthcare is provided through the publicly funded NHS, the involvement of the private sector is more limited and to date has mainly provided more short term solutions, often focusing on technological improvements. That said, the healthcare sector in the UK is, and has been for many years, very proactive in tackling fraud, certainly compared to some of their other government counterparts and there is no reason to think that this wont continue. However, this webinar has shown that to counter fraud in the long term it is important to share information and work with all partners involved in the provision of healthcare.

Dr Janice Goldstraw-White
6th July 2023

What’s the latest?

Join our brand new Security & Risk Thought Leadership Newsletter