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Expert comes up with honest answer to frauds ACC will need to be the first gov dept audited

#1 User is offline   doppelganger 

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Posted 05 October 2009 - 04:30 PM

Expert comes up with honest answer to frauds
4:00AM Monday Oct 05, 2009
By Adam Bennett
Fraud may be costing New Zealand's public and private organisations as much as 8 per cent of their income or expenditure, says British anti-fraud consultant Jim Gee.

He believes it is time to "get smart" and focus on prevention rather than detection.

Gee, a counter-fraud specialist for more than 25 years, is head of fraud and forensic services at MacIntyre Hudson.

Having reviewed the New Zealand Ministry of Health's counter-fraud arrangements in 2007, he will be in the country again shortly with his work as a principal in the Protect Consortium, a group of senior New Zealand and UK specialists working to protect public organisations - and their money - against fraud.

Gee told the Business Herald a big part of his work in recent years had been helping develop ways to accurately measure total fraud losses within organisations, "pretty much like they would know any other cost they have such as staffing, procurement or accommodation".

Of those exercises, 58 have shown losses are somewhere between 3 and 8 per cent of income or expenditure.

He sees no reason why, despite perceptions that corruption is a relatively small problem in New Zealand, that its organisations are not suffering a similar level of losses.

"That's quite a lot of money when you think about the amount of money that's spent in your public sector or the UK public sector.

"Indeed it's quite a lot of money in any decent sized private sector company."

Gee believes gauging the scale of the problem is essential to coming up with solutions.

Much anti-fraud work has involved solutions based on quite an anecdotal and unscientific understanding of what the problem is, "but if you understand how big your problem is you can invest in the solution proportionately".

For Gee that has meant moving away from a reactive approach and developing pre-emptive solutions.

"I set up and ran an organisation to protect the UK National Health Service from fraud and even after eight years with 500 people we were only detecting something like one-thirtieth of all the fraud taking place. When we realised there were limits to how good you could be at detecting it and stopping it, we got smart, we started to do more work around changing the culture of organisations.

"Somebody once said to me that of all people there are about 10 per cent who are pretty much always dishonest, 10 per cent who are honest and 80 per cent who are opportunists.

"If you can change the proportions there, change some of the opportunists into a category where they're always honest, if you can do what we call "mobilise the honest majority" then you can create really strong peer group pressure and then you can use that peer group pressure to shrink the size of the group that are dishonest then you have less people attempting fraud in the first place that's less fraud you have to prevent and detect."

"There are many different things you can do, but you fundamentally have to make sure people understand they gain more by behaving well rather than behaving badly.

" In the NHS we redistributed some of savings from fraud, it went back specifically to pay for better patient care. People rapidly learned they gained more from helping us and working with us than from perpetrating fraud."

Gee and his team reduced NHS fraud losses by up to 60 per cent, giving more than 800 million ($1780 million) worth of benefits.

Gee admits this approach is not effective against low-volume high value fraud of the type that tends to get the most coverage in the media, "but the measurement exercises show that the greatest economic losses to organisations whether public or private sector, whatever country they're in, come from much more mundane high-volume low value fraud".

Copyright 2009, APN Holdings NZ Limited

just look at the figures.

10% are dishonest

80% are opportunists

10% are honest

ACC management have over the years turned the opportunists into dishonest persons by showing the opportunists how to commit fraud IMO

#2 User is offline   MINI 

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Posted 05 October 2009 - 05:06 PM


That is extrodinary.

What he is saying is that the high value rip off up the top in one of the big hospitals down south in the past year, which saw a few high heads roll for disappearance of millions of dollars is not as harmful or of as much value as say a few rip off's on ACC for a few years.

Bulls dust, it would take a few dishonest claimants to rip of the same value as they did and over a much greater period of time.

Mind you us being one of the few countries that has ACC as part of our health system, it would be very difficult to try the quantify any similarity. Don't you just love it when the americans or english come in to tell how to do things properly. It is not because we do not have the expertise, it is because the govt do not trust their own to not use the information they have against them. Like insider trading.

One thing it would be interesting to value is the amount that is saved through ACC not being honest and fraudulent. Never mind about the claimant, try the corporation for similarity.

In other words how much is insider related fraud compared with claimant fraud?? I have a serious thought that the odds would wiegh very heavily on the corporation getting the most value from dishonest behaviour. And then one could go one more step in the same direction and find out who benefits from that behaviour.

Good read, interesting topic. Totally sad outcome. 80% dishonest, because opportunists, even if the commit fraud but once is still dishonest. The amount of times you do it can not take the FACT away, that you have done it. Opportunities happen every day, do you take them every day, does that still make you an Opportunist.

Now I know exactly why I am wierd, I only make up 10% of the population, the honest ones. It makes one open to all sorts of garbage doesnt it?? Because people who admit you are honest, will know exactly what your reaction will be at any given time to any given suggestion.



#3 User is offline   hukildaspida 

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Posted 08 October 2009 - 03:09 PM

Who is in the Protect Consortium Group?

What is the Privacy Commissioners opinion on this serious matter as Patient Information of course will be under scrutiny once more by whom?

See this thread for further information which may be of interest relating to Jim Gee, as interelated.

Whilst we have no issue with Fraud, as it is refered to being Investigated, isn't that the role of the Police or do they no longer investigate such alleged criminal activities?

How much more of our Public Funds & Levies do we need to be disbursed on these kind of outfits which no doubt will be run by 'Failed Cops" who have perfed from the Police on Psychological grounds?

Jim Gee advised Frank Field who is/was U.K Minister for Welfare Reform, & was director general of the European Healthcare Fraud & Corruption Network 2004-2006
The folllowing Memorandum of Understanding re American Healthcare etc was signed as recently as 4 August 2009.

Big Brother is sure watching you.

#4 User is offline   hukildaspida 

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Posted 01 October 2012 - 08:48 PM

Actors in fraud and corruption

Healthcare systems are prone to fraud and corruption because of the large number of players involved and because they can interact in many and complex ways. Based on a report from Transparency International [1] these players can be classified into five main categories:

Government regulators (health ministries, parliaments, specialized commissions)
Financers (social security institutions, government office, public and private insurers)
Healthcare providers (hospitals, doctors, pharmacists)
Suppliers (medical equipment and pharmaceutical companies)

The number of players increases the difficulties of producing and analysing information and identifying fraud and corruption when it occurs. It also increases the number of opportunities for corruption; for example, funds can be diverted at a ministry, state hospital board, or local clinic by individuals working as managers, procurement officers, health professionals, dispenser, clerks or patients.


Global Corruption Report 2006, Transparency International, 2006

Government regulators

It is common for governmental bodies such as health ministries, parliaments, specialised commissions, to assume the role of verifying that medications are safe and effective, that healthcare providers have completed approved courses or have proven skills, and that facilities are adequately staffed and equipped. However, the fact that there are regulations also opens potential for corrupt activities. Examples include:

Pharmaceutical companies can skew research studies, influence review boards or bribe regulators to approve or speed up the processing of their applications to register and sell medical products, medicines or antibiotic products.
Regulators can receive illegal payments in order to take an advantageous decision regarding the inclusion of medicines on the list of reimbursed medicines.
Healthcare providers and facilities may be tempted to pay a regulator to overlook lapses in licensing requirements.
Government inspectors can be tempted to abuse their position to extract bribes even when providers are in compliance.

hukildaspida says: this can equally apply accross all sectors of the Medical Profession & in future this should be specified.

Professional Fraud and Corruption
Healthcare providers can have a wide range of opportunities to engage in fraud and corrupt activities. Examples include, but are not limited to fraud and corruption by:

General Practitioners

General Practitioners claiming for patients they have actually not treated.

General Practitioners creating details of patients for treatment under state-funded or discounted health schemes that do not exist.

Medical professionals lying about their qualifications to receive fees or higher salaries that they are not entitled to.

Medical professionals separating out various aspects of treatment to give the appearance of numerous procedures and for the purpose of billing the paying authority more.

Medical professionals asking for and receiving an informal payment from patients awaiting treatment, generally under the understanding that they would then receive the treatment quickly.

Staff at hospitals

Staff member submitting falsified timesheets claiming for hours not worked to receive a higher wage packet

Payroll staff creating fictitious staff members and diverting the wages or salaries into bank accounts they have access to.

Staff member providing fictitious qualification details to obtain a promotion or pay rise.

Manager falsifying performance statistics to receive a larger pay bonus.

People successfully applying for jobs using falsified qualifications, references or work experience.

Managers diverting funds from their business area for their own personal use.

Senior management signing off altered or fictitious financial statements as correct.

Other healthcare providers

Dentists charging patients privately and also submit claims to the health insurer.
Opticians claiming that two pairs of glasses were issued to a patient when only one pair was actually issued.
Physiotherapists claiminign for services not performed or claiming more services than actually supplied.


Pharmacists substituting expensive drugs with a cheaper alternative, but claiming for the expensive one.
Pharmacists adding items to prescriptions.
Pharmacists selling medicines without prescription to wholesalers for illegal export.
Pharmacists invoicing non-delivered drugs.

It is important to be aware that fraud and corruption can take many different forms, and that the perpetrators committing these crimes are always looking for new openings through which to commit them.

#5 User is offline   hukildaspida 

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Posted 27 March 2014 - 01:39 PM

An update on Jim Gee who is quoted in the above posts.

How does the NZ health sector compare?

There have been a number of "Professionals" whom have been caught over the years with their hands in the jar.

It also impacts on how much we pay in funds to operate hospitals & our levies.

How many "Fraud Investigators" does NZ have in the same arena?

NHS fraud could be as high as £5bn a year, says former health service official

Former counter-fraud director Jim Gee says health service losses could be 20 times higher than official government figure

James Meikle
* The Guardian, Monday 24 March 2014


Fraud may be costing the NHS £5bn a year, more than 20 times the government's official figures, with at least another £1bn being lost due to financial errors, according to a former senior official responsible for tackling the crime.

Jim Gee said the health service loses 7% of its budget annually to fraud and mistakes, amounting to about £7bn, and most of that was down to crime. Official statistics, which show £229m of losses through patients and dentists making false financial claims, are "completely implausible", he said. The government disputes Gee's estimates.

He told the BBC's Panorama programme due to be screened on Monday night that if the NHS was losing only this amount "it would be doing 30 times better than any other healthcare organisation in the world".

Government figures ignored losses that might be taking place in payroll and procurement, areas where there was "great potential for fraud", according to Gee. He is the former director of NHS counter-fraud services, who now chairs the advisory board of Portsmouth University's centre for fraud studies and is an author of the centre's report on the issue to be published this week.

Panorama says its own freedom of information requests reveal there are just over 300 fraud investigators in NHS Protect, the body responsible for tackling economic crime against the service in England and Wales. The Department of Work and Pensions employs six times that number to combat benefit cheats, the programme says.

Gee said the NHS staff wanted to do more but did not have the resources to do the job. "Cutting the budget of NHS Protect sends a message to fraudsters that there will be greater opportunities for them to gather their ill-gotten gains."

Panorama will give examples of individual frauds, including stolen medical products being sold on eBay, a GP using patient records to obtain prescriptions for drug addiction and dentists charging for unnecessary procedures or work they have not done.

The Department of Health
told Panorama in a statement it "did not recognise" Gee's figures, and added last night: "Fraud against the NHS is a crime that can have a serious impact on our ability to deliver high quality health services. Any allegation or suspicion of fraud should be referred to NHS Protect who are required to take appropriate action. When fraud is proven, we expect all appropriate sanctions and recovery action to take place."

Andrew Gwynne, shadow health minister,
said ministers must explain why the NHS was "haemorrhaging" the amounts suggested by Gee. "After David Cameron's costly reorganisation, it can ill afford further ministerial incompetence. Patients are already paying the price.

"The government must account to parliament for this scandalous abuse of precious NHS resources and explain how it will put an end to it."

The £229m figure comes from the government's Annual Fraud Indicator, which only offers two specific areas of NHS fraud, £156m for patients falsely claiming exemption from charges, including for prescriptions, and £73m for dentists making false claims. It says, however, there may be £2.3bn worth of procurement fraud affecting the UK public sector and £335m in payroll fraud in England, Scotland and Wales.

Last week, a Rochdale GP who stole over £62,000 from the NHS was sentenced to nine months' imprisonment, suspended for 18 months, and ordered to pay £50,000 costs by Minshull Street Crown Court, Manchester. Thirumurugan Sundaresan admitted falsifying the records of 1,703 patients to hit targets and increase payments from the NHS to his practice.

Earlier this month, Joyce Trail, a Birmingham dentist jailed for seven years in 2012 for stealing £1.4m from the NHS, was issued with court orders that should see substantial sums given back to the health service. The NHS is also taking steps to cancel her pension.


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