By NextBestFitPhase 5: Stabilize & govern · Step 5.2
Run program integrity & fraud control
Year 1 onward · UHA Program Integrity; HHS-OIG; DOJDiscuss this step
How other countries handled this same piece of implementation, what happened, and what it means for this plan.
Side by side
| Country | Approach | Result | Lesson for this plan |
|---|---|---|---|
| This plan (U.S.) | With one payer, fraud schemes that exploit gaps between payers disappear, but every scheme now targets one payer. UHP funds fraud control at a higher rate than Medicare does today. | ||
| Taiwan | Real-time claims analytics and the smart card flag duplicate prescriptions and suspicious billing. | Low fraud rates relative to spending. | Centralized data enables real-time fraud prevention. |
| Germany | Sickness funds and physician associations run plausibility checks on billing. | Fraud persists but is policed by peers and payers. | Professional self-regulation complements payer audits. |
Taiwan
- What they did
- Real-time claims analytics and the smart card flag duplicate prescriptions and suspicious billing.
- What happened
- Low fraud rates relative to spending.
- Lesson for this plan
- Centralized data enables real-time fraud prevention.
Germany
- What they did
- Sickness funds and physician associations run plausibility checks on billing.
- What happened
- Fraud persists but is policed by peers and payers.
- Lesson for this plan
- Professional self-regulation complements payer audits.
More precedent
- Medicare's Fraud Prevention System (2011); Taiwan's real-time NHI claims analytics.