Five Ways Health IT Leaders Can Fight Medicare Fraud

The role of EMR

Electronic medical records can help identify fraud and reduce waste, Markopolos said. As systems gather and store more and more data, it will be easier to identify trends and outliers.

On the other hand, the lack of paper means there's one less trail to follow.

And EMRs themselves can be a source of fraud. For example, pharmaceutical companies can illegally pay for a high ranking on lists of treatment options. Markopolos says smaller practices, in particular, are susceptible if they use a vendor's pre-loaded formularies. Practices should create their own lists of medications, he said.

What to do?

Markopolos wants IT and other healthcare leaders to join him in the hunt for fraud. There are five ways they can help, he said.

1. Get educated. It's the first thing that IT and other healthcare professionals must do, Markopolos said. One way to do that is to get involved in professional organizations that have codes of conduct that members must follow.


2. Look for trends and changes in data. If a source of revenue jumps from 3% to 6% with no obvious reason, IT leaders should speak up. You can also compare data with other organizations in your area.


3. Beware of vendors bearing gifts. Gifts from pharmaceutical or medical device makers are "low-hanging fruit" for fraud investigators, Markopolos said. Even if an organization chooses a device because it really does best suit its needs, it is still fraud to receive any form of compensation from the maker—and can lead to jail time. "If vendors are sending you money, that's a big problem," Markopolos said. "You don't get paid enough to put on an orange jump suit." Consider following the lead of organizations that have banned all gifts from representatives and companies, he added


4. Do some profiling. Those with a propensity toward fraud tend to have a sense of entitlement, especially among doctors who feel they should be making more money. They rationalize their behavior, Markopolos said.


5. Blow the whistle. If you do see fraud, speak up—even if you were involved. Why? The government tends to treat whistleblowers well, protecting their identity and giving them deals in which they can avoid prosecution. The government is looking to identify higher-ups. To blow the whistle, go to the government, the press, or call an anonymous hotline. But don't go to your organization's lawyers, he said. Or, for that matter, anyone in the C-Suite. Rather, work with your chief compliance officer if you suspect fraud.

What's next?

The government will spend more money and get more aggressive about investigation and enforcement if the healthcare industry can't get fraud under control on its own, Markopolos said. "That's the future."

One tool the government might use? Undercover patients.

Undercover work has been "a proven law-enforcement tool," Markopolos said. And it could be coming to a hospital or physician practice near you. Patients who are well will visit doctors to see if they get treatments and procedures they don't need, or if the doctors bill for work they didn't do. Hearing aids, tie clips, or pens equipped with audio and video will collect evidence that's hard to dispute.

"It's probably the wave of the future," Markopolos said.