Category Archives: Health Care

A Holistic Approach to Reducing Fraud, Waste, and Abuse


Overview

Under the current administration, there is a renewed emphasis on reducing fraud, waste, and abuse (FWA) within the Federal Government.  While this is nothing new, historical initiatives have focused primarily on external threats and only moderately succeeded at reducing operational waste and have made little to no impact in identifying the fraud and abuse prevalent in certain areas of Government.  Historical approaches are top heavy, punitive, and rely on self or third party reporting with only negative consequences for those involved.

Figure 1Decades of experience show that fraud, waste, and abuse can be attributed to three sources: the external threat; the internal threat; and internal/external collaboration.  First, the external threat has received a lot of attention.  In this case, new laws, policies and systems (Figure 2) have been enacted to proactively identify and reduce fraud perpetrated by outside actors.  The second type of threat is the collaborative threat.  In this case, the threat is an external force working with unethical or willingly naïve officials within the Government.  This type of offense is often the most highly publicized aspect of FWA.  The third type of FWA is the internal threat.  In this case, internal Government personnel manipulate resources and abuse the system for unintended purposes.

As mentioned above, a number of important laws and policies have been implemented since 2002 with growing success in reducing the external threat.

Figure 2As we move forward in reducing FWA one must understand that the methods used for external threats do not apply universally to collaborative and internal threats.  The introduction of an insider as part of the equation creates a very different risk profile for the agency.  There are political and cultural implications when exposing an insider threat that do not exist with purely external threats.

To understand FWA and its threat to the Government and Taxpayers, we must come to terms with a common definition.  This is not as simple as it may seem and even with a definition, it is hard to determine what falls where without more clarification.  For the case of this paper, we will use the definition currently being used by the Department of Veterans Affairs (Figure 3).

Figure 3
With a working definition of FWA and an understanding of the FWA Triple Threat (Figure 1), we can now begin to address the issue that appears to be hiding in plain sight, the Internal Threat.   The internal threat comes in many forms, some examples are:

  • Low-Price Technically Acceptable (LPTA) acquisitions for non-commodities.
  • The various forms of acquisition fraud
  • Duplicative programs and functions within or across agencies refusing to consolidate due to the “Uniqueness” of their program or mission on even the most basic of functions (i.e. badging, billing, human resources, acquisitions)
  • Promotions and bonuses in offices/agencies with declining performance and rising inefficiency
  • Artificial barriers to improvement (e.g., Union Agreements)

A New Approach

While current Government initiatives are focused on identifying fraud from external threats and the IG is investigating issues as they are identified, Management Science & Innovation (MSI) has devised a new approach to addressing fraud, waste, and abuse.  Rather than relying on intra-agency inspection and whistle-blowers to identify the effects of internal threats, we propose using a data driven and statistically sound analysis to reduce fraud, waste, and abuse within our organizations in the same way that we are beginning to defend ourselves from external threats.

The MSI approach requires organizations to proactively identify fraud, waste, and abuse and report it along with remediation strategies in a non-punitive manner.  Each organization is given six months to conduct an internal analysis on FWA using an approach that starts with operational outcomes as the handle for pulling threads that can lead to FWA issues.  This analysis is conducted by a third party, ideally from another agency or with contractor resources that are willing to accept OCI restrictions on future work, using proven risk detection, modeling, and analysis tools.

As part of the self-reporting phase, reporting organizations are immune from punitive action, unless egregious or clearly illegal behavior is detected, so long as they propose sound remediation strategies and where possible demonstrate action already taken. Reporting organizations are also given the opportunity to propose expected operational efficiency and effectiveness gains as well as a rewards and punishments system for staff.  From this foundation, the organization is tasked with two things: 1) executing remediation strategies and conducting any internal rewards/punishments and 2) implementing a system for detection and reporting of FWA that will integrate with the agency and Government programs for the elimination of FWA.  Organizations are also informed at the beginning of the process that should they report no findings in the initial six month study, there will be a complete FWA review of their program by the inspector general.

This new approach addresses the concern of FWA from a more positive perspective that emphasizes and prioritizes operational outcomes and works with organizations to understand the impact of removing FWA within their organization.  Additionally, it reemphasizes the importance of reducing the impact of waste by helping employees truly understand what waste is (Figure 4) and how it impacts Stakeholders.  In the case of the Department of Veterans Affairs we can redirect the conversation to the impact on the Veteran for example (Hypothetical):

  1. $100,000 in unnecessary overtime is equal to 10 Veterans receiving Dialysis Figure 4Treatments.
  2. $500,000 in improper billing is equal to housing as many as 50 homeless Veterans for a year.
  3. $1,000,000 in unnecessary acquisition costs is equal to as many as 10 additional Veterans receiving prosthetic limbs.

By refocusing the conversation on the stakeholders and applying a less punitive approach to detecting and preventing FWA, It gives motivated staff (the non-offenders) the opportunity to act in a positive manner and it gives the offenders an opportunity to change their ways and become part of the solution.  Ultimately, this new approach should transform the culture from one in which FWA is ignored and sometimes even tolerated to the point of being condoned to one where even the hint of FWA is adjudicated swiftly.

While there are a great number of organizations and leaders who will  stand up and praise there efforts to eliminate FWA.  These efforts are focused on the external threat unless an internal or collaborative threat has been exposed to them and the world by an outside source.  Unless a serious effort is taken to address the Internal threat and begin to undergo the serious transformational change effort that our government is crying out for,  we will never begin to scratch the surface on eliminating fraud, waste and abuse within our government.

 

For more information contact:

info@msipros.com

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Effective Government Coalition


August 2016

Effective Government Coalition – Exploratory Phase

The Effective Government Coalition (EGC) announces its non-partisan mission to create an efficient and streamlined government that lives up to the same operations standards, efficiency, and integrity that the American people have come to expect and require from public companies and businesses that affect their everyday lives from the 21st Century.

The Effective Government Coalition is comprised of some of the nation’s top experts in business process improvement and operations management including Lean Six Sigma experts, CEOs, COOs and process and systems experts from all political backgrounds. The Coalition is comprised of people of all generations from baby-boomers to the recently designated largest generation in America; the 75+ million strong millennials.

Creating an effective and efficient government in which Americans have faith is vital to the future sustainability of American democracy, opportunity and prosperity. Currently, faith in government is at an all-time low due to the continued mismanagement of funds, programs and more. This is because many government officials are forced to manage bad processes.

The Coalition is recruiting all Americans who wish to reshape the Federal Government in a way that allows every tax dollar to be spent creating positive value for tax payers by identifying and eliminating waste, redundancies, fraud, and abuse in all federally controlled programs, systems, and processes. To do this, the Coalition will promote the use of strategically-driven performance improvement capabilities across the entire Federal Government to increase efficiency and effectiveness.

Annual waste estimates from all government and government-affiliated entities range from $200 billion to $1 trillion with a 10-year savings in the trillions.

Imagine all the ways that this money could be put to more effective use.

A focused top-down driven effort will reorient government to provide effective services, reduce the cost of government, grow our economy, accelerate job creation, restore faith and trust and keep America on top of the world economy. Most importantly, this effort will drive a reduction in the national debt; a debt that is being passed down to future generations.

The Coalition will build public support for its mission and present government officials with ideas and research on concrete steps on how to move towards an effective and more efficient government that is expected of America in the 21st century.

The Coalition will work towards its goals by utilizing the collective resources of the members, their firms and their experience in the private, public and political sectors.

Please join us on this very important mission by visiting our link and signing up.

http://egcoalition.com/

 

Sincerely,

The Founding Coalition

  • Chairman, Founder: Kellen Giuda, NY, NY
  • Founder: David Allway, Washington, DC
  • Founder: Jack Merritt & Bill Casey, Philadelphia, PA

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