I’m going to summarize some points that Dr. Marty Makary made in his manifesto for why he wrote his most recent book. The Price We Pay is its name. You can hear this manifesto in his own words—in Dr. Makary’s own words—on Relentless Health Value episode 242, but here’s his point: He said that the 2007 banking crisis, writ large, resulted from complexity that kept onlookers confused. So, when people questioned the banks being overleveraged and selling mortgages to, you know, those who couldn’t afford them, experts responded by saying, “You know, it’s very complicated. Leave it to us.” But on the ground, it was clear there was a problem. And in hindsight, there obviously was a problem.
Here’s the point that Dr. Makary was making, which I think is super valid: Many of the entrenched stakeholders in medicine fend off criticism by claiming that these are highly complex systems that should be left to experts. They say, “You wouldn’t understand. Leave it to us.” And just like the experts in the banking industry got us into the calamitous Great Recession in 2007-2008, the experts that we’re leaving it to in health care have driven ever-higher prices for care that I’m gonna say that most in the health care industry who actually care about patients are certainly not proud of.
In this health care podcast, I’m speaking with Dawn Cornelis, cofounder and director of transparency at ClaimInformatics. We get into what sounds so simple: self-insured employers having their medical bills paid by a third party who specializes in paying medical bills. Maybe these third parties even say that they give all the bills the once-over before they pay them—except when a company like ClaimInformatics reviews the same bills, they find savings in the double digits from paying bills that are wrong at some level or just flat-out fraud.
Considering that by some estimates there’s like a trillion dollars lost in this country to some level of fraud, waste, and abuse, this is pretty much the opposite of poking around in the couch cushions looking for change. While there’s certainly a lot of details, it’s not really that complicated.
You can learn more at claiminformatics.com or by emailing Dawn at d.cornelis@claiminformatics.com.
Dawn Cornelis is cofounder of ClaimInformatics and serves as its chief transparency officer. With 25 years of experience in health care claim review and cost containment, Dawn brings a personal passion for rooting out fraud, waste, and abuse. Dawn’s work includes building strong national alliance partnerships with major insurance companies and health systems such as AIG World Investigative Resources, Global Options, Mutual of Omaha, Principal Financial Group, Deloitte, PHCS/Multiplan, Jefferson Health System, and Seton Health System. Dawn has identified and recovered hundreds of millions of dollars of improper payments through pre- and post-payment cost containment programs while navigating the payment systems of all of the national health carriers.
In 1993, Dawn cofounded Claim Recovery Services, the industry’s first audit and recovery firm, and served for 17 years as its chief operating officer, assisting several Fortune 100 companies. She then spent 3 years as the chief operating officer of ClaimReturn.
Dawn has been an expert speaker at national forums such as The Institute for HealthCare Consumerism on various health care audit topics and participates in roundtable sessions on federal and state regulations.
02:54 The story in the data.
03:32 Who’s submitting these claims?
04:10 The three problems with the data.
07:19 The varying factor between carrier systems to stop fraud, waste, and abuse.
07:59 Why carriers don’t push for better systems to stop inappropriate dollars.
10:07 The difference between fraud, waste, and abuse.
11:46 “When it becomes the norm, that’s what’s very bothering.”
12:13 The barriers or hurdles in the marketplace.
15:35 What we don’t know about but could do better at when looking at the data.
18:01 “It’s not so much the health system and what they are charging. It’s about … what the contracted rate is agreed to. That’s what drives our costs.”
19:02 “Data’s fixed for itself.”
22:09 Identifying and eliminating fraud.
22:14 Unbundling and the lack of enforcement behind preventing illegal billing.
28:59 How providers ensure they aren’t inadvertently harming employers and patients through billing.