There are a lot of new and exciting health care information technology (IT) companies sprouting up. Most are taking advantage of the many opportunities made possible by the Affordable Care Act, aka Obamacare. These startups are using large amounts of anonymous data from Medicare, Medicaid and private insurance databases and their own sophisticated algorithms to make health insurance and health care easier to purchase and use.

This is all great stuff but health care has an even bigger problem that these data mining and analyzing geniuses can and should address. The problem is health care fraud—a multi-billion dollar a year problem. Technology firms should create algorithms to scan health care claims and financial data to identify and prevent fraud. This type of sophisticated response is needed because health care fraud perpetrators are usually insiders that are very good at crafting and hiding their schemes.

Unfortunately, creating health care fraud detection algorithms may be the easy part for the tech industry. The challenge for these firms is working with the health care industry usual suspects including medical providers, insurers, associations and government regulators.

The health care industry is a special kind of place with several factions fighting hard to protect their members’ interests. There is also the issue of navigating a highly regulated industry and interacting with multiple government agencies. It’s kind of like old school meets new school with old school having more money, a huge head start in regards to understanding the industry and its regulations and established relationships with government policymakers. But if the nation is serious about reducing health care fraud, it is going to need the help of big data analyzing IT firms.

Health Care Fraud Is A Huge Problem Continue Reading...

Tags: obamacare, HIPAA

I'm having a Bernie Sanders moment. I cannot stop obsessing over how pharmaceutical and health care providers and insurers continue to use their political power to keep lining their pockets at the expense of average Americans. Correction. At the expense of the entire country...

We need a system to match the power of these powerful interests if we are ever going to rein in health care costs. And that system has got to be Medicare For All—a national health insurance program funded by taxpayers and employers. Medicare For All will require sacrifices from everyone, but that’s exactly why it can work. It puts everyone on an even playing field for a base level of care with no judgment attached. However, it doesn’t prevent those who can afford it from purchasing additional health insurance coverage. This is my vision of Medicare For All.

• A basic national health insurance program that provides health insurance coverage from birth
• A program that regulates medical and prescription drug prices
• A program that provides more than catastrophic medical care, but does not provide unlimited care
• A program that focuses on value and outcomes

1. Everyone learns how health insurance works from the very beginning. There is no this group gets an insurance card, pays no premiums, seeks emergency care only and has no idea how insurance works, while this group pays a subsidized premium, seeks preventive and necessary care and knows what health insurance is. Everyone is introduced to the Medicare For All system at the same time, under the same rules and structure so that everyone knows what health insurance is and how to use it.

Get ready. We are about to get knee deep in the annual benefits open enrollment season. This includes open enrollments for Medicare, healthcare.gov and private sector health plans.

This is also the time of year that health care and health insurance policy wonks and writers comb through the latest health insurance surveys. The producers of these surveys include non-profits dedicated to health research and policy; employee benefits consulting firms, private research firms and human resource management associations.

Some of the organizations providing these surveys include:

• Kaiser Employer Health Benefits Survey
• Bureau of Labor Statistics Employee Benefits Survey
• Marsh & McLennan Mid-Market Group Benefits Survey
• SHRM Employee Benefits Survey
• Mercer's National Survey of Employer-Sponsored Health Plans

Tags: Surveys, Affordable Care Act

These days nearly every Human Resource department has a wellness function. Larger firms often employ full-time staff to run the program.  However, for most midsize or smaller firms it’s a Benefits pro or HR generalist side gig.  It is these folks who are responsible for coordinating wellness testing and related events.  And right now is their busiest time of year--the “Opening Act” so to speak for the annual benefits open enrollment period.

I don’t envy these folks. Workplace wellness is not an enjoyable gig. Employees hate the intrusiveness of the program and employers; well they just use it as an excuse to look like they are trying to keep health care costs down. Just ask any “Wellness Coordinator” what their biggest gripe is and trust me it won’t be about lack of employee engagement. The biggest gripe these folks have is the constant pressure to keep the numbers up. And not the numbers you think.

• How many employees received flu shots?
• How many employees received biometric screenings?
• How many employees attended this quarter's wellness lunch and learn session?

Tags: wellness programs