As policymakers increasingly focus on waste, fraud and abuse in healthcare, it's worth examining where these concerns originate – and where solutions already exist. Today's healthcare systems have built sophisticated systems to prevent, detect, and address these issues, often before they arise.
The view from the frontlines
Healthcare providers understand that every dollar lost to waste or fraud is a dollar that can't be invested in patient care. That's why organizations like Novant Health have developed comprehensive compliance programs that go well beyond what regulations require.
Consider what this looks like in practice: More than 40,000 team members receive not just annual compliance training, but role-specific education on billing practices, coding accuracy and regulatory changes. Contractors and third-party service providers must meet these same standards. Advanced analytics continuously monitor billing patterns and clinical documentation, flagging anomalies for immediate review. When concerns arise –whether through 24/7 reporting hotlines, exit interviews, or data analysis – structured investigation protocols ensure swift, appropriate responses.
This isn't simply about meeting requirements. It's about building a culture where integrity is embedded in daily operations, from boardroom oversight to bedside care.
The broader healthcare ecosystem
While what happens inside our walls is critical, healthcare delivery involves many participants beyond hospitals and clinicians. Each plays an essential role: insurers helping patients access coverage, pharmacy benefit managers negotiating drug prices, vendors providing critical services and consultants offering specialized expertise.
Yet the complexity of these interconnected relationships can sometimes create inefficiencies. When administrative processes become labyrinthine or pricing lacks transparency, resources that could support patient care may be diverted elsewhere. These systemic challenges contribute to the very inefficiencies that concern policymakers and may inadvertently create opportunities for waste to occur across the healthcare continuum.
Building effective solutions together
The most promising path forward recognizes that comprehensive solutions must address the entire healthcare ecosystem: providers, insurers, pharmacy benefit managers, vendors and others. Effective policy would build on existing compliance strengths while ensuring consistent standards of accountability and transparency across all parts of the healthcare sector.
Smart policy development could:
- Leverage existing compliance programs where they're already robust
- Address gaps in oversight across all healthcare sectors
- Promote transparency in pricing and coverage decisions
- Reduce administrative complexity that drives up costs without improving care
- Focus on outcomes rather than prescriptive processes
A shared responsibility
Preventing waste, fraud and abuse in healthcare is a shared commitment that requires all participants to maintain high standards of integrity. Providers like Novant Health have demonstrated this commitment through substantial investments in compliance programs. Similar strong action across every part of the healthcare ecosystem would ensure that resources flow to their intended purpose: improving the health and wellbeing of patients and communities. By taking a comprehensive view – recognizing both existing strengths and areas needing attention – we can create more effective policies that protect patients and preserve resources for care.
