Project Mission

Priority actions within our «Fight Fraud» project are aimed at making joint efforts to strengthen the healthcare system and bring the maximum benefit to America. We focus on identifying and mitigation of fraud risks in the Healthcare sector.

Annually The Office of Inspector General (OIG) collects and presents statistical data reported by Medicaid Fraud Control Units (MFCUs or Units) who investigate and prosecute Medicaid provider fraud and patient abuse or neglect.

Fraud convictions accounted for 73 percent of all convictions for the last 5 years.

According to data from the U. S Department of Health and Human Services Medicaid Fraud Control Units Fiscal year 2017 annual report stated that criminal recoveries of $693 million in FY 2017 were almost double those from FY 2016. The majority of this amount—about $519 million—came from the Texas MFCU, which prosecuted a large case involving a doctor and other codefendants who defrauded Medicaid and Medicare by improperly recruiting individuals and falsifying medical documents. This shows that fraudulent activities increased despite government measures taken to prevent fraudulent activities.

The above data represent only those individuals and entities who have been convicted for fraud, which amounted only to 20% of the total number of frauds. Many are never caught.

We strongly believe that billers and billing entities must be the first level of defense that stops unlawful claims submission. WCH has a well-designed strategy and vision for fraud prevention when billing for medical services.

The «Fight Fraud» project will significantly decrease financial losses for federal programs like Medicare and Medicaid, bring the most outsourced jobs back to America and raise the medical billing profession to a higher level within the healthcare community. This program does not require significant funds from state organization but rather will bring money back to the state budget.

Program Benefits:

a. Financial gain for the states, government funds

b. Saving benefits of Medicare and Medicaid for future generations

c. Licensing access to People’s Money

d. Raise of billing to a higher professional level and bringing jobs back to US.

e. Creating new jobs

f. Significant reduction of a billing fraud

g. Decrease in the number of poor medical documentation that contains errors or fraud

Project objectives

• Fraud must be reduced, we estimate approximately a 25% reduction in the first 12 months

• Decrease the number of billing entities

• Remaining entities will serve as enforcers as well as reputable health compliant entities

• Better control, oversight and management of a $100 million medical billing industry

Details

Through this project, students will be expected to:

1. Devise a development strategy for “Fight Fraud” project in line with its mission and objectives.

2. Create a business plan to implement the program to the federal level. It is necessary that the «Fight Fraud» project to become a part of the government programs.

3. Think how to build and develop a professional team for this project. Determine what would be the roles of the members of such team for timely achievement of the project main strategic objectives.

4. Identify promotional channels for the program and analyze what would be the effective strategy for sustainable use of the channels.

5. Ensure a relationship between development strategies, business plan and project budget.

6. Analyze the potential for government funding and funding from international financial institutions.

7. Prepare a database that will include state and federal contacts, who may help to move the program to the federal level.

8. Examine options of mutually beneficial cooperation of WCH with health professional organizations, private funds, government and any other companies/organizations that would have interest in cooperating and which may support to move the program to the federal level.