💡Verify Then Trust

How can we ensure integrity in a system so complex and sprawling? For years, the industry relied on a pay and chase model—paying claims first, then chasing down errors and fraud after the fact. But as the landscape evolves, a shift is underway.

It's no longer about simply reacting to errors; it’s about proactively verifying before making payments, ensuring that we can trust the data before it’s processed. The concept of "verify then trust" is now more crucial than ever.

A Critical Insight: The Burden of Proof

Eric Rubenstein, MSCJ, CFE highlighted a powerful insight in response to a recent court ruling involving UnitedHealth Group. The ruling set a dangerous precedent by allowing a company to keep overpayments, despite its own internal audits showing errors. The government was unable to prove the overpayments were fraudulent because they didn’t conduct their own review.

The takeaway here isn’t just that the company got away with it—it’s that this ruling makes it easier for others to avoid accountability. Why fix overpayments when you can just keep the cash? And why comply with fraud laws if you know the burden of proof lies with the government?

Eric's point is simple: it is the government's burden to prove malfeasance, not the company’s to disprove it. While companies should be good corporate citizens, the legal framework often gives them a loophole to escape responsibility—unless proactive checks are in place.

The Shift to Proactive Verification: Stop and Verify

The solution to this growing problem lies in the shift from reactive approaches to a proactive verification model. It’s no longer enough to wait for fraud to be detected post-payment. Instead, the industry is moving toward “stop but verify” systems, where claims are verified before payment is made. This ensures that fraud and waste are caught before they have a chance to impact the system.

The key is proactive verification. By instituting processes that verify the data before releasing payments, we can avoid the costly aftermath of chasing fraud down the road. This model doesn’t just stop fraud in its tracks—it also builds trust in the system.

As the industry shifts, so must our approach. It’s no longer enough to trust the claims blindly—we must verify first, then trust that what we’ve verified is legitimate.

This mindset is crucial in a landscape where healthcare dollars are limited, and fraud can run rampant without the right checks in place.

The Future: A Culture of Verification and Trust

We absolutely must instill a culture of verification in every step of the process. By doing so, we are setting a new standard for accountability and transparency.

As Eric Rubenstein, MSCJ, CFE pointed out, the importance of verifying before trusting cannot be overstated. If we continue to trust blindly, we risk perpetuating the same cycle of fraud and inefficiency. Stop and verify—that’s the new mantra for ensuring integrity in healthcare programs.

The future of healthcare integrity is proactive, and it starts with verifying first.