Electronic fraud detection in the U.S. Medicaid Healthcare Program: lessons learned from other industries

It is estimated that between $600 and$850 billion annually is lost to fraud, waste, and abuse in the US healthcare system,with $125 to$175 billion of this due to fraudulent activity (Kelley 2009). Medicaid, a state-run, federally-matchedgovernment program which accounts for roughly one-quarter of all healthcare expenses in the US, has been particularlysusceptible targets for fraud in recent years. With escalating overall healthcare costs, payers, especially government-runprograms, must seek savings throughout the system to maintain reasonable quality of care standards. As such, the need foreffective fraud detection and prevention is critical. Electronic fraud detection systems are widely used in the insurance,telecommunications, and financial sectors. What lessons can be learned from these efforts and applied to improve frauddetection in the Medicaid health care program? In this paper, we conduct a systematic literature study to analyze theapplicability of existing electronic fraud detection techniques in similar industries to the US Medicaid program

State regulation of the national currency exchange rate by gold and foreign currency reserve management

Status of the national currency of Ukraine exchange rate has been characterized as unstable in recent years. Herewith, the Government has not implemented decisive measures on its stabilization, as a rule, underestimating the importance of the Hryvnia exchange rate stability for the successful economic growth in terms of socio-economic transformations. It should also be noted that in modern conditions among scientific and methodical approaches to the State exchange rate formation mechanisms some uncertainty regarding basic and additional tools for such regulatory activities allocation is still persist. The problem relevance is exacerbated by the lack of effective policy (coordination between the NBU and the Government actions) regarding the national currency stabilization as an indispensable prerequisite for an effective macroeconomic development. These circumstances determine the importance of factors influencing the national currency exchange rate and its regulation tools research, as well as new organizational and economic mechanisms for the national currency exchange rate in Ukraine stabilization identification. In the emerging market economy conditions formation of the efficient State currency exchange-rate regulation system provides an opportunity not only to stabilize its exchange rate in different socio-economic conditions, but to create the basis for improvement the country economic development as a whole. Given this, the issue of effective tools for the national currency exchange-rate regulation by the state determination is of theoretical, practical and methodological significance. This emphasizes the relevance of further scientific-methodological and practical principles in-depth development for the national currency exchange-rate regulation

PRODUCTION TERMINATION AS AN ALTERNATIVE TO MITIGATE NUTRIENT POLLUTION

Nutrient runoff from agricultural land can be reduced through production termination to mitigate water pollution. The willingness to accept value to terminate the broiler production is evaluated using sample selection model. The result showed a positive relationship between the decision to participation and stated WTA value indicating the producers are willing to terminate the production but at high cost. The farmer’s perception about government role on water pollution, farm income, information and awareness about other pollution reduction alternatives play a major role on stated WTA amount as well as on participation decision.Environmental Economics and Policy,

Contract Design for Biodiversity Procurement

Market based instruments are proving e¤ective in biodiversity procure- ment and in the management of regulatory schemes to preserve biodiversity. The design of these schemes brings together issues in auction design, con- tract theory, ecology, and monitoring. Using a mixed adverse selection, moral hazard procurement model, we show that optimal contract design may di¤er signi?cantly between procurement and regulatory policy environ- mentsbiodiversity; procurement; adverse selection; contract theory

State Implementation of National Health Reform: Harnessing Federal Resources to Meet State Policy Goals

Discusses state options for maximizing coverage and access to care; reforming the health insurance market; holding insurers accountable for high-quality, affordable coverage; restructuring healthcare delivery and financing; and cutting budget deficits

Healthcare reform in Russia: problems and prospects

This paper examines the prospects for reform of Russia’s healthcare system. It begins by exploring a number of fundamental imbalances that characterise the current half-reformed system of healthcare provision before going on to assess the government’s plans for going ahead with healthcare reform over the medium term. The challenges it faces include strengthening primary care provision and reducing the current over-reliance on tertiary care; restructuring the incentives facing healthcare providers; and completing the reform of the system of mandatory medical insurance

Independent Evaluation of the Water and Sanitation Hibah Program Indonesia

This evaluation assess the effectiveness of Indonesia's Water and Sanitation Hibah Program pilot and identifies lessons for applying this mechanism more broadly. The program, which operates by paying an agreed amount for verified household water or sanitation service connections installed by local water and sanitation utilities, takes advantage of excess capacity of water companies to bypass the need for infrastructure investment. It was evaluated through a document review, key informant interviews, a key stakeholder workshop, field work, and a beneficiary survey, along with quantitative data from existing sources

Strengthening governance of social safety nets in East Asia

Several East Asian countries, in the aftermath of the global financial crisis, are considering an expansion of their social safety net programs. In many cases, existing delivery mechanisms for social assistance in the region tend to be basic, in line with the small size of programs. In a context of coverage expansion and proliferation of new programs, the risk of creating increasingly complex systems characterized by cross-incentives is high. Lack of coordination, ambiguous criteria for identifying and selecting beneficiaries, low administrative capacity, lack of transparency and limited beneficiary participation pose risks for program effectiveness and can decrease accountability. Good governance can improve program outcomes through effective program coordination, stronger accountability arrangements, provider incentives and greater transparency and participation. This paper proposes an analytical framework to systematically identify governance risks and constraints which, if removed, could improve the outcomes of modern social assistance programs.Health Monitoring&Evaluation,Safety Nets and Transfers,National Governance,Governance Indicators,Poverty Monitoring&Analysis