Conclusion
A tremendous amount of work is needed to ensure the protection of the health care payments sector from criminal activity . Although this can be daunting , it is achievable , assuming those involved enlist the help of true subject-matter experts and quicken their stride to build the necessary risk infrastructures to protect and preserve a critical function within our society .
Dustin J . Eaton , CFE , CFCI , CAFP , CGSS , CCCI , CCI , CAFCA , risk management and fraud professional , djenzwm @ yahoo . com
Derek McDaniel , solutions architect , Hummingbird
1
Nikhil R . Sahni , Prakriti Mishra , Brandon Carrus , et al , “ Administrative Simplification : How to Save a Quarter-Trillion Dollars in US Healthcare ,” McKinsey & Company , October 2021 , https :// www . mckinsey . com / industries / healthcare-systems-andservices / our-insights / administrative-simplification-how-to-save-a-quarter-trilliondollars-in-us-healthcare
2
“ Understanding the Cost of Ineffective Payment Integrity Operations ,” Healthpayer Intelligence , October 31 , 2022 , https :// healthpayerintelligence . com / news / understanding-the-cost-of-ineffective-payment-integrity-operations
3
Historical ( National Health Expenditure Data ), Centers for Medicare & Medicaid Services , Office of the Actuary , National Health Statistics Group ; U . S . Department of Commerce , Bureau of Economic Analysis ; and U . S . Bureau of the Census , https :// www . cms . gov / Research-Statistics-Data-and-Systems / Statistics-Trends-and- Reports / NationalHealthExpendData / NationalHealthAccountsHistorical
4
“ National Money Laundering Risk Assessment ,” U . S . Department of the Treasury , February 2022 , https :// home . treasury . gov / system / files / 136 / 2022-National- Money-Laundering-Risk-Assessment . pdf
5
“ Facts & Statistics ,” U . S . Department of Justice , August 6 , 2021 , https :// www . justice . gov / criminal-fraud / facts-statistics
6
Nikhil R . Sahni , Prakriti Mishra , Brandon Carrus , et al , “ Administrative Simplification : How to Save a Quarter-Trillion Dollars in US Healthcare ,” McKinsey & Company , October 2021 , https :// www . mckinsey . com / industries / healthcare-systems-andservices / our-insights / administrative-simplification-how-to-save-a-quarter-trilliondollars-in-us-healthcare
7
Ibid .
8
Ibid .
9
Ibid .
10
“ Cyber Criminals Targeting Healthcare Payment Processors , Costing Victims Millions in Losses ,” Federal Bureau of Investigation , September 14 , 2022 , https :// www . ic3 . gov / Media / News / 2022 / 220914-2 . pdf
11
Neena Hagen , “ 40 Million Americans ’ Health Data is Stolen or Exposed Each Year . See if Your Provider has been Breached ,” USA Today , November 29 , 2022 , https :// www . usatoday . com / story / news / 2022 / 11 / 29 / electronic-medical-records-cyberattackhealthcare-data-breach-database / 8323526001 /
12
Paul Abbate , “ Internet Crime Report 2020 ,” Federal Bureau of Investigation : Internet Crime Complaint Center , https :// www . ic3 . gov / Media / PDF / AnnualReport / 2020 _ IC3Report . pdf
13
Paul Abbate , “ Internet Crime Report 2021 ,” Federal Bureau of Investigation : Internet Crime Complaint Center , https :// www . ic3 . gov / Media / PDF / AnnualReport / 2021 _ IC3Report . pdf
14
Nikhil R . Sahni , Prakriti Mishra , Brandon Carrus , et al , “ Administrative Simplification : How to Save a Quarter-Trillion Dollars in US Healthcare ,” McKinsey & Company , October 2021 , https :// www . mckinsey . com / industries / healthcare-systems-andservices / our-insights / administrative-simplification-how-to-save-a-quarter-trilliondollars-in-us-healthcare
15
Ibid .
16
Ted Seides , “ Episode 06 : Partnering , Merging , and Growing at Zelis ,” Capital Allocators , November 23 , 2022 , https :// capitalallocators . com / podcast / partnering-mergingand-growing-at-zelis /
17
“ MLN Booklet : Medicare Fraud & Abuse : Prevent , Detect , Report ,” Centers for Medicare & Medicaid Services and Medicare Learning Network , January 2021 , https :// www . cms . gov / Outreach-and-Education / Medicare-Learning-Network-MLN / MLNProducts / Downloads / Fraud-Abuse-MLN4649244 . pdf
18
“ Understanding the Cost of Ineffective Payment Integrity Operations ,” Healthpayer Intelligence , October 31 , 2022 , https :// healthpayerintelligence . com / news / understanding-the-cost-of-ineffective-payment-integrity-operations
19
“ MLN Booklet : Medicare Fraud & Abuse : Prevent , Detect , Report ,” Centers for Medicare & Medicaid Services and Medicare Learning Network , January 2021 , https :// www . cms . gov / Outreach-and-Education / Medicare-Learning-Network-MLN / MLNProducts / Downloads / Fraud-Abuse-MLN4649244 . pdf
20
Abigail Zuger , “ Tallying the Waste in American Healthcare ,” NEJM Journal Watch , January 5 , 2021 , https :// www . jwatch . org / na52991 / 2021 / 01 / 05 / tallying-wasteamerican-healthcare
21
Steve Alder , “ Automation Can Help Network Defenders Achieve More in Less Time and Stay One Step Ahead of Hackers ,” HIPAA Journal , December 14 , 2022 , https :// www . hipaajournal . com / automation-can-help-network-defenders-achievemore-in-less-time-and-stay-one-step-ahead-of-hackers /
22
Priscilla Holland , “ How ACH Payments Can Help Healthcare Providers ,” Payments Journal , March 7 , 2014 , https :// www . paymentsjournal . com / how-ach-payments-can-help-healthcare-providers /
23
“ Understanding the Cost of Ineffective Payment Integrity Operations ,” Healthpayer Intelligence , October 31 , 2022 , https :// healthpayerintelligence . com / news / understanding-the-cost-of-ineffective-payment-integrity-operations
24
Susan Hogan , Rick Yarborough , Carlos Olazagasti , et al , “ Thousands of Postal Carriers Assaulted or Robbed Since 2020 : USPIS Data ,” NBC Washington , May 20 , 2022 , https :// www . nbcwashington . com / investigations / thousands-of-postal-carriersassaulted-or-robbed-since-2020-uspis-data / 3057513 /
25
Ben Leonard , “ Hackers Have Laid Siege to U . S . Healthcare and a Tiny HHS Agency is Buckling Under the Pressure ,” Politico , August 28 , 2022 , https :// www . politico . com / news / 2022 / 08 / 28 / hackers-have-laid-siege-to-u-s-health-care-and-a-tiny-hhsagency-is-buckling-under-the-pressure-00053941
26
“ Cyber Criminals Targeting Healthcare Payment Processors , Costing Victims Millions in Losses ,” Federal Bureau of Investigation , September 14 , 2022 , https :// www . ic3 . gov / Media / News / 2022 / 220914-2 . pdf
ACAMS Today September – November 2023 45