License to Steal-How Fraud Bleeds America's Health Care System, updated edition. . - book review

FBI Law Enforcement Bulletin,The, Jan, 2002 by James A. Robertson

License to Steal-How Fraud Bleeds America's Health Care System, updated edition by Dr. Malcolm K. Sparrow, Westview Press, Boulder, Colorado, 2000.

Few crime problems in the United States have grown as rapidly and extensively as health care fraud. In 1999, federal health care fraud efforts produced a 16 percent increase in criminal indictments, 396 convictions, 2,278 civil matters pending, and $524 million obtained from judgments, settlements, and administrative proceedings. With such alarming statistics in mind, Dr. Malcolm Sparrow's updated book, License to Steal-How Fraud Bleeds America Health Care System, stands as a comprehensive, analytical, illustrative, and useful tool not only for investigators, but also for anyone even remotely connected to this issue.

Dr. Sparrow begins by contrasting and comparing the perspectives of the insurance industry, government, and consumers. He describes the insurance industry as an attractive target of fraud, or socially acceptable victim, which correctly reflects attitudes of many of the insured (i.e., customers), as well as that of the insurance criminal. This is especially true for government insurance programs. His evidence points to one Medicare contractor claims official who said, "it's not our money...just government money passing through." That same official went on to say, "you know the cheapest way to process a claim? Pay it without question." Dr. Sparrow further illustrates this failed approach to safeguarding health care dollars with the quote of one industry official who stated that the approach in fighting health care fraud to date has been "to pay and chase." He also cites a 1998 study of actions taken by medical licensing boards against corrupt practitioners, which showed that 57 percent had no action taken agai nst them and, more astonishing, 82 percent retained their licenses as practitioners. This clearly reflects a tolerant and indifferent attitude.

He then describes, in great detail, how controls to date have failed. This is followed by a chapter that describes the tremendous federal effort during the 1990s to combat health care fraud and the industry's response.

As a main attribute, this book offers a detailed proposed solution to the problem that Dr. Sparrow terms, "A Model Fraud-Control Strategy." However, having concluded that health care fraud remains uncontrolled, he maintains that two essential things must happen before this model strategy can become a reality. First, the industry, government, and the public must understand the complexity of the fraud control challenge. And, second, they must learn the true extent of the crime problem through a commitment to systematic measurement. In describing this model strategy, the author illustrates just how different the model is from the current practice in both the private and public sector.

Dr. Sparrow's credentials and perspective also add to the validity of the information he provides. A former detective chief inspector with the British police service, he currently teaches regulatory and enforcement strategy and analytical methods at Harvard's John F. Kennedy School of Government. He also specializes in risk control and is the acknowledged national expert on the subject of health care fraud. With this background and perspective, he has employed some of the most knowledgeable and cooperative sources of information, from both the private and public sector, in his research and provides a comprehensive explanation of the nature of this complex problem.