Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Market Overview: Implications for Prevention, Detection, and Investigation

“The great enemy of the truth is very often not the lie—deliberate, contrived, and dishonest—but the myth—persistent, persuasive, and unrealistic.” If the U.S. market is going to make a serious dent in healthcare expenditures, it will involve a discussion that employer-linked healthcare is not working and is detrimental to U.S. employers in a global economy. The market is currently discussing the concept of price transparency. Unfortunately, it is mostly limited to the insulation between the patient and the provider. Price transparency is truly about removing all insulation. Any mandates imposed on the provider should also be imposed on the relationship between the payer and the employer and all parties identified within the HCC.

It is interesting to read articles written from the payer perspective that blame cost shifting on the government programs. The private-payer market existed prior to the implementation of Medicare. Its birth was driven by the people shift of noncovered, high-risk individuals by the private sector. In an attempt to control prices, Medicare placed price caps. These price caps drove the shifting of costs back to the private-payer market. The private-payer market shifted back to the employer market. The employer market shifted back to its employees. The question now is: to whom does the employee or the patient shift back to? The implication for prevention, detection, and investigation ...