A KNOWLEDGE MANAGEMENT APPROACH TO HEALTH CARE

ANTI-FRAUD EFFORTS: GETTING THE PATIENT INVOLVED

_______________

A Thesis

Presented to the

Faculty of

San Diego State University

_______________

In Partial Fulfillment

of the Requirements for the Degree

Master

of

Business Administration

_______________

by

Matthew David Strandberg

Spring 2011
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Copyright © 2011

by

Matthew David Strandberg

All Rights Reserved

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DEDICATION

This thesis is dedicated to my wife, Dana, without whose support and patience the
completion of this work would have been exceedingly more difficult.
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ABSTRACT OF THE THESIS

A Knowledge Management Approach to Health Care Anti-Fraud

Efforts: Getting the Patient Involved
by
Matthew David Strandberg
Master of Business Administration
San Diego State University, 2011

Fraud, waste and abuse are increasing dilemmas affecting the U.S. health care system.
According to estimates by the National Healthcare Anti-Fraud Association and other
concerned entities, fraud may account for as much as 10% of healthcare spending per annum.
This percentage translates to approximately $220 billion per year in wasted funds,
representing significant and negative economic implications for both the public and private
sectors. Beyond its economic impacts, health care fraud has a broad social dimension; as the
environment and nature of fraudulent activities continue to evolve, organized crime
syndicates have established a foothold and, in addition, schemes have recently emerged that
put patients at substantial risk of physical harm. While the problem of health care fraud has
received relatively little academic attention in comparison to other domains, its monetary
impacts are enormous and the dynamics of the issue are growing in their complexity; as such,
further study and proposed solutions are warranted.
A number of systems have been developed, and several significant collaborative
efforts initiated, in an attempt to combat the problem of health care fraud. Current software
tools are rules-based decision support systems, which cannot effectively identify many types
of fraud. Attempts at collaboration have mainly involved law enforcement and payers; these
undertakings have been somewhat successful, but limited in their effectiveness. This thesis
argues that a primary factor in the ineffectiveness of current and recent solutions is the lack
of involvement in collaborative exchange by patients. Using a knowledge management
approach, leveraging fundamentals of the discipline and lessons learned, the current
environment of health care fraud is analyzed. In particular, barriers to patient participation
are studied and recommendations made for facilitating their active involvement in attacking
the problem of fraud. Recommended solutions include a model for an effective distributed
knowledge management system that is usable by and to all parties to health care transactions,
including patients.
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TABLE OF CONTENTS

PAGE

ABSTRACT ...............................................................................................................................v
LIST OF TABLES ................................................................................................................... ix
LIST OF FIGURES ...................................................................................................................x
ACKNOWLEDGEMENTS ..................................................................................................... xi
CHAPTER
1 INTRODUCTION .........................................................................................................1 
Background ..............................................................................................................1 
Statement of the Problem .........................................................................................2 
Purpose of the Study ................................................................................................6 
Theoretical Bases and Organization ........................................................................6 
2 REVIEW OF THE LITERATURE .............................................................................10 
Economic Implications ..........................................................................................10 
Social Considerations.............................................................................................11 
Common Forms Of Fraud ......................................................................................13 
Billing for Services Not Provided ....................................................................14 
Misrepresentations ...........................................................................................15 
Rendering of Medically-Unnecessary Services ...............................................16 
Upcoding, Unbundling and Related Billing Practices .....................................16 
Public Sector Attempts at Combating the Problem ...............................................16 
Private Sector Attempts at Combating the Problem ..............................................19 
Challenges in Public-Private Sector Collaboration..........................................20 
Commercial Fraud Detection Tools and Methodologies .................................21 
The Concept of Knowledge ...................................................................................22 
Definitions and Objectives of Knowledge Management .......................................23 
The Growing Role of Knowledge Management in Health Care Industry
Applications ...........................................................................................................25 
Communities of Practice ........................................................................................27 
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Knowledge Management Systems: Planning and Considerations .........................29 

KM System Success Factors ............................................................................30 
Evolving Framework of the KM Discipline ..........................................................31 
Barriers to Collaborative Participation ..................................................................32 
Differences in Terminology Usage and Understanding...................................32 
Patient Concerns Related to Data Privacy and Security ..................................37 
Failure to Identify and Include a Relevant Stakeholder...................................40 
Lack of Awareness or Interest of the Problem Domain ...................................42 
Inadequate Level of Technical Sophistication .................................................43 
Motivating Factors for Participation ......................................................................44 
Characteristics and Value of Patient Knowledge...................................................45 
Rules-Based and Expert Systems...........................................................................47 
3 METHODOLOGY ......................................................................................................49 
Design of the Investigation ....................................................................................49 
Population ..............................................................................................................50 
Protection of Human Subjects ...............................................................................51 
Treatment of Data ..................................................................................................51 
Data Analysis Procedures ......................................................................................52 
An In-Depth Look at the Model.............................................................................52 
4 RESULTS AND DISCUSSION ..................................................................................56 
Presentation of the Findings...................................................................................56 
Understanding of Terminology, Provider Instructions and Common
Documents .......................................................................................................56 
Awareness of the Problem Domain .................................................................57 
Attitudes toward the Problem ..........................................................................58 
Sharing (Actual and Willingness) ....................................................................58 
Demographics and Background .......................................................................59 
Technical Abilities ...........................................................................................59 
Discussion of the Findings .....................................................................................63 
5 A PROPOSED KM SYSTEM MODEL ......................................................................66 
Review of Current Approaches and Challenges within the Problem
Domain ...................................................................................................................66 
A New Approach ...................................................................................................68 
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Challenges in Design and Implementation ............................................................69 

Shared Understanding of Health and Medical Terminology ...........................69 
Legal Considerations .......................................................................................70 
Security and Privacy Considerations ...............................................................70 
Encouraging Patient Participation....................................................................70 
Critical Success Factors .........................................................................................71 
Provide Effective Privacy Preferences and Controls .......................................71 
Get the Right Information to the Right People at the Right Time ...................71 
Include and Capture Knowledge from All Relevant Stakeholders ..................72 
Facilitate Communication between Parties of Diverse Vocabulary Sets.........72 
Ease and Convenience of Use ..........................................................................73 
Effective Search Functionality: Locating Knowledge .....................................73 
Create Shared Context .....................................................................................75 
Focus on the Future ..........................................................................................75 
Create a Knowledge-Friendly Culture .............................................................75 
Appropriate Technical Infrastructure ...............................................................75 
Extending the Concept of a Community of Practice .............................................76 
Model Taxonomy and Ontology ............................................................................77 
System Architecture and Other Technical Considerations ....................................79 
“Hubs” for Organization and Granular Control ...............................................79 
User Types .......................................................................................................81 
Peer-to-Peer (P2P) Network Architecture .......................................................82 
Towards the Implementation of a System Based Upon the Model .......................83 
Final Remarks on the Proposed Model ..................................................................84 
6 SUMMARY, RECOMMENDATIONS AND CONCLUSIONS................................85 
REFERENCES ........................................................................................................................88 
APPENDIX
STUDY QUESTIONNAIRE .............................................................................................93 
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LIST OF TABLES

PAGE

Table 1. Qui Tam Cases in Health Care as a Percentage of Total Qui Tam Cases,
1993 to 1998 ................................................................................................................43 
Table 2. Understanding of Common Documents ....................................................................56 
Table 3. Understanding of Terminology, Provider Instructions, Common Documents ..........57 
Table 4. Awareness of Problem Domain .................................................................................57 
Table 5. Attitudes Toward the Problem of Health Care Fraud ................................................58 
Table 6. Sharing of Personal Health Information ....................................................................58 
Table 7. Technical Abilities (Respondent Self-Assessment) ...................................................59 
Table 8. Model Summary for Regression of Willingness to Participate on Major
Independent Variables .................................................................................................60 
Table 9. ANOVA Results for Overall Regression ...................................................................61 
Table 10. Regression Coefficients for the Overall Model Regression ....................................61 
Table 11. Overall Result of Regression of Medical Terminology Understanding on
Background and Technical Abilities. ...........................................................................62 
Table 12. ANOVA Test for Regression of Medical Terminology Understanding on
Background and Technical Abilities. ...........................................................................62 
Table 13. Listing of Coefficients for the Regression of Medical Terminology
Understanding on Background and Technical Abilities. .............................................62 
Table 14. Overall Result of Regression of Problem Awareness on Background and
Technical Abilities. ......................................................................................................63 
Table 15. ANOVA Test for the Regression of Problem Domain Awareness on
Background and Technical Abilities. ...........................................................................63 
Table 16. Listing of Coefficients for Regression of Problem Domain Awareness on
Background and Technical Abilities. ...........................................................................63 
Table 17. Representation of a Diagnosis Object by the Proposed System ..............................79 
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LIST OF FIGURES

PAGE

Figure 1. Hypothesized linkages between contributors to patient participation. .......................4 

Figure 2. The role of knowledge in anti-fraud cases. ................................................................5 
Figure 3. Expected impact of knowledge on anti-fraud efforts, by stakeholder. .......................7 
Figure 4. Level and degree of impact of anti-fraud components. ..............................................8 
Figure 5. Estimated contribution to health care fraud, by type of behavior. ...........................14 
Figure 6. Illustration of Nonaka’s SECI model. ......................................................................46 
Figure 7. Major pre-defined object types supported by the proposed system. ........................78 
Figure 8. Example of hub-based architecture used to express relationships between
objects within the proposed system. ............................................................................80 
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ACKNOWLEDGEMENTS

I would like to take this opportunity to express my sincere gratitude to Dr. Murray
Jennex, the chair of my thesis committee, for his guidance and direction throughout the
process. In addition, I would like to thank Drs. Addo and Frost for recognizing the potential
value of this thesis and agreeing to serve as members of the committee.
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CHAPTER 1

INTRODUCTION

This thesis begins with a brief overview of the issue of health care fraud, followed by
a more formal and precise statement of the problem. Subsequently, rationale and justification
for the study is presented. Finally, the theoretical bases of the study are put forth.

BACKGROUND
Health care fraud adversely and significantly affects both public and private benefit
frameworks, ranging from federal and state programs such as Medicare and Medicaid to
commercial and employer-sponsored insurance plans. Losses resulting from fraud, waste and
abuse have contributed heavily to the rising costs of health care that characterize the current
industry environment. While fraud has not been the only catalyst in health care cost increases
(development and implementation of new medical equipment and technologies, treatments
and pharmaceuticals have also helped to fuel increases), it has played a substantial role.
These rising costs have made insurance coverage unaffordable, and thus unavailable, for
millions of Americans and their families. Monetary effects associated with health care fraud
are staggering from the business perspective, particularly for insurance payers who are forced
to absorb much of the costs as well as to pass them along to all parties with whom they do
business.
Beyond obvious impacts to health care accessibility, these forces directly act against
the nation’s GDP. According to estimates by the National Health Care Anti-Fraud
Association (2009) and other concerned entities, fraud may account for as much as 10% of
healthcare spending per annum. This percentage translates to approximately $220 billion per
year in wasted funds.
In addition to its economic impacts, health care fraud has a broad social dimension; as
the environment and nature of fraudulent activities continue to evolve, organized crime
syndicates have established a foothold and, in addition, schemes have recently emerged that
put patients at substantial risk of physical harm. While the problem of health care fraud has
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received relatively little academic attention in comparison to other domains, its monetary
impacts are enormous and the dynamics of the issue are growing in their complexity; as such,
further study and proposed solutions are warranted. Within this thesis the current
environment surrounding healthcare fraud will be discussed at length, including a substantial
overview of several key government and private-sector actions that have been taken in an
attempt to combat the problem; the relative success of these efforts will be analyzed.
A number of systems have been developed, and several significant collaborative
efforts initiated, in an attempt to combat the problem of health care fraud. Current software
tools are rules-based decision support systems, which cannot effectively identify many types
of fraud. Attempts at collaboration have mainly involved law enforcement and payers; these
undertakings have been somewhat successful, but limited in their effectiveness. This thesis
argues that a primary factor in the ineffectiveness of current and recent solutions is the lack
of involvement in collaborative exchange by patients. Using a knowledge management
approach, leveraging fundamentals of the discipline and lessons learned, the current
environment of health care fraud is analyzed. In particular, barriers to patient participation
are studied and recommendations made for facilitating their active involvement in attacking
the problem of fraud. Recommended solutions include a model for an effective distributed
knowledge management system that is usable by all stakeholders to health care transactions,
including patients.

STATEMENT OF THE PROBLEM

Consumers, or patients, have been largely uninvolved in strategic collaborations
created for exchange of knowledge related to the problem domain. Several private-sector
initiatives for information sharing have explicitly excluded patients from participating.
Internal efforts by payers within their organizations have also disregarded patient knowledge;
most rely upon rules-based DSS software for identification of suspicious claims during the
adjudication process. This thesis argues that the failure of health care industry entities to
make any attempt at capturing patient knowledge constitutes a glaring error. Such exclusion
ignores the significant evidence which exists within the KM (knowledge management)
literature supporting the benefits of careful identification and leverage of available and useful
knowledge sources. This thesis investigates barriers to effective patient participation in anti-
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fraud collaborative efforts and, additionally, identifies opportunities that may exist to lower
or eliminate such barriers.
Health care fraud is essentially a game of asymmetric information. Of all the players
involved in a typical health care transaction arising from a clinical encounter, two entities
possess substantially more information than the rest; these are the provider (first and
foremost) and the patient. Both of these entities, and only these entities, know everything that
transpired during their encounter. While the provider has the advantage of medical education,
experience and familiarity with health and medical jargon, the patient still knows what
services were performed, although may understand it (and may explain it to others)
somewhat differently than the provider. The level of knowledge that these entities possess is
substantially greater than all other stakeholders involved in the claims adjudication
workflow. The stakeholder armed with the next-highest level of information is the payer, but
such information is second-hand in nature.
Returning to the problem discussed previously, current efforts towards the combat of
health care fraud have only sought to capture knowledge from one of the two entities who
possess first-hand knowledge of the encounter upon which the payment transaction is based:
the provider. Unfortunately for the payer, and as is discussed in the literature review (Chapter
2) providers are the primary perpetrators of fraud within the health care industry; due to the
power of the information asymmetry dynamic, lax enforcement and insufficient fraud
detection methodologies, the provider as stakeholder has incentives to report incorrect
information to the payer that can be difficult to validate (or refute).
This paper views the understanding of medical terminology (to include jargon, terms
and industry-accepted coding systems) as a significant prerequisite for a patient’s ability to
effectively participate in efforts aimed at a reduction in economic and social externalities
caused by health care fraud. Terminological matters are a core concept within the knowledge
management domain, as they play a major role in knowledge transfer and application,
primarily due to considerations of common context of understanding. Taxonomies,
ontologies and controlled vocabularies are frequently encountered in the KM literature and
can each directly or indirectly address terminological challenges. This paper argues that
patients (in general) currently lack sufficient understanding of health and medical
terminology to play an effective role in health care anti-fraud efforts. Provider billing
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statements, explanation of benefit (EOB) statements from payers and much of the other
documentation currently used within the health care industry makes heavy use of complex
medical terms and complicated code sets. Without the ability to interpret what procedure(s)
have been billed to a patient’s insurance carrier (payer), how effectively could a patient
identify discrepancies between the services actually performed and what was actually billed?
If, indeed, diversity in terminological understanding between patients and providers is
preventing patients’ effective participation, how might concepts of knowledge management
be applied and leveraged to improve the situation? Issues surrounding understanding of
terminology will be discussed in greater detail throughout the thesis.
In addition to the aforementioned examination of terminology concerns, this thesis
presents and tests additional hypotheses surrounding consumer awareness (of the problem of
health care fraud and its magnitude), current attitudes toward the problem, willingness to
share information (with the goal of expanding the anti-fraud knowledge base), and others.
Figure 1 shows each of the expected relationships examined by the present study. Each
relationship indicated in the diagram is a study hypothesis and these will be revisited in the
Methodology chapter (Chapter 3), where rationale for the relationships are explained and a
functional model is derived for purposes of analysis.

Figure 1. Hypothesized linkages between contributors to patient participation.

As is illustrated in Figure 1, this thesis postulates that demographics (background)

and technical understanding are related both to how well a patient might understand health
and medical terminology, as well as to the patient’s level of awareness of the problem
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domain. Further, it is postulated that a patient’s willingness or ability to participate in health

care anti-fraud activities will be dependent upon terminological understanding, awareness of
the problem domain, willingness to share information and involvement in his or her own
personal health. The importance of knowledge in combating fraud and creating positive
economic and social outcomes is reflected in Figure 2.

Figure 2. The role of knowledge in anti-fraud cases.

Knowledge captured from and shared between payers, law enforcement and
regulatory bodies is currently used, along with resources such as law enforcement time and
government funds, in conducting investigations related to suspected fraudulent activities
within the health care industry. Depending on the success of an investigation, further action
may result in the form of civil cases, criminal prosecutions or both. Such actions can result in
monetary penalties (fines), recoveries of funds (belonging to the public trust or to private
payers) and industry sanctions (such as revocation of privileges or prohibition against
administering services to Medicare or Medicaid patients) against offenders.
Currently, knowledge is not captured directly from patients. This is indicated in
Figure 2 by the dashed line around the representation of patient knowledge. With an
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estimated high value of patient knowledge, it is reasonable to expect both more, and more
fruitful, investigations and subsequent actions working against the problem.

PURPOSE OF THE STUDY

The primary objective of this study is to enhance and further anti-fraud collaboration
activities that incorporate patient knowledge capture, in order to increase the effectiveness of
such efforts. The significance of the present investigation is two-fold. Firstly, there is
insufficient recent academic research on the subject of health care fraud; what little could be
found during the literature review process was at least ten years old, and additionally, was
lacking in depth. It is arguable that, in many domains, the matter of whether prior research
was conducted recently is of minor importance. However, the subject domain of this thesis –
health care fraud – is characterized by a dynamic, complex and evolving environment where
older interpretations of key issues can become less relevant. For example, the nature of the
fraudulent schemes themselves, the approaches to enforcement, and the typical profiles of
health care fraud perpetrators have all continued to change fairly rapidly over the last ten
years. Further, and as a direct consequence of the domain evolution just described, the
required knowledge needed to effectively attack the problem continues to change.
The second basis for the present work is that the magnitudes of the problem’s
economic and social implications warrant such study. In addition, the study now undertaken
and described within this paper approaches the problem domain from a unique perspective;
concepts developed within the knowledge management discipline are used for analysis and
understanding of key limitations to existing approaches and solutions, as well as in
application to a proposed model that attempts to largely overcome these limiting factors.

THEORETICAL BASES AND ORGANIZATION

Literature relevant to this study consists of a number of prior investigations and
analyses surrounding explicit barriers to participation in collaborative frameworks,
understanding of health and medical terminology by patients and other parties to health care
transactions, as well as general research related to success factors for development and
adoption of effective knowledge management systems. These studies are used within this
thesis in combination with a survey instrument, in order to assess barriers to patient
participation in health care anti-fraud efforts and propose potential solutions.
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This paper argues that the failure to include, and thus capture, knowledge from
patients in previous and current collaborative forums within the fraud domain has limited the
success of anti-fraud efforts; further argued is that this failure has been detrimental to payers,
taxpayers, societal interests and the national economy. For purposes of understanding the
current environment, justifying the study’s hypotheses and in order to develop and present
potential solutions, this paper applies knowledge management principles to each.
For instance and in reference to the above, several recent knowledge management
undertakings have revolved around distributed KM systems that span organizational borders
for knowledge capture and internalization. This thesis argues that it is both logical and
straightforward to build upon and extend the dynamics of a DKMS to the specific domain of
health care fraud. In addition, the conceptual bases surrounding communities of practice,
while not historically used for such purposes, fit well with a theoretical collaborative
framework that involves all key stakeholders involved in health care transactions, including
the patient. In terms of patient understanding of medical terminology and the manner in
which this creates challenges in comprehending payer documents and in articulating
information, it is reasonable to consider and apply the concepts of tacit and implicit
knowledge, particularly with respect to developing solutions to increase effective patient
knowledge capture.
With respect to anti-fraud efforts and value of information from diverse sources, the
expected impact of knowledge from the various stakeholders of the health care industry and
the health care anti-fraud domain is shown in Figure 3.

Figure 3. Expected impact of knowledge on anti-fraud efforts, by stakeholder.

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Beginning from the lower end of the knowledge impact spectrum, this paper
considers provider knowledge capture to be of the lowest impact, for several reasons; some
of these reasons have already been discussed in this chapter, but are restated here. Providers
are the most common perpetrator of fraudulent activities within the health care industry,
primarily using inappropriate billing practices when such fraud has been committed. As a
result, treating this stakeholder as a source of truth involves an element of danger. In the
middle of the spectrum sits law enforcement and regulatory agencies, who can offer valuable
insights based on experiences in prior anti-fraud investigations and court cases. At the high
end of the spectrum are patients, whose knowledge capture is considered most critical by this
paper. Patients are a first-hand source of knowledge about their own clinical encounters with
providers, and as both a member of the payer’s health plan and as a taxpayer, this stakeholder
has significant incentives to participate as a whistleblower against fraudulent activities.
Figure 4 illustrates the important components, or ingredients, to combating health
care fraud. The diagram shows both the expected level and degree of impact from each
component.

Figure 4. Level and degree of impact of anti-fraud components.

As shown in Figure 4, this paper argues that knowledge is the most critical
component of effective anti-fraud activities. Knowledge exposes common fraudulent
schemes, suspicious billing practices, various discrepancies and so forth, which can be used
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by all stakeholders together to better understand the dynamics of the problem domain, and
consequently, to take effective actions. Diverse knowledge is available for capture from all
stakeholders. Collaboration is also extremely important, but is placed lower on the impact
spectrum than knowledge because contextually-relevant, timely and useful knowledge is
necessary as the basis for active, effective collaboration. Similarly, effective enforcement
depends upon collaboration in terms of shared purpose and exchange of information. Moving
further down, it is fair to state that regulations (in the form of laws and statutes) are only
effective if enforced. Finally, sense of moral obligation (and resultant self-regulation) is a
component which presumably plays some role in limiting fraudulent behaviors before they
begin.
This paper begins with a comprehensive review of the relevant literature surrounding
health care fraud and subsequently continues with a discussion of the knowledge
management discipline and its growing role in health care-specific applications. Next, the
thesis discusses the study methodology and presents findings and recommendations related to
the results of the investigation; the presented recommendations include a proposed model for
a distributed KM system that supports effective participation by all health care stakeholders.
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CHAPTER 2

REVIEW OF THE LITERATURE

This chapter begins with an examination of the history and dynamics surrounding
health care fraud, in order to provide the reader with the necessary context with which to
appreciate the significance of the problem and need for this study. The chapter begins with an
analysis of socio-economic implications and subsequently proceeds to a discussion of the
most common forms of fraud currently affecting the industry. The review of literature
concerning the problem domain ends with an examination, in reasonable detail, of public and
private sector attempts at combating the problem of fraud.
Next, a review of relevant literature is presented to the reader which covers the
knowledge management, or KM, discipline, with moderate to heavy emphasis placed on
elements of participation and KM system design. This subject matter is considered in the
framework of understanding the role of patients as a group (for instance, as users within a
distributed KM system, or simply as a member of a community of practice) and the
importance of capturing information and knowledge from members of this role by current
participants in anti-fraud research, investigation and enforcement activities.

ECONOMIC IMPLICATIONS
A review of the literature surrounding the actual monetary effects of health care fraud
reveals a wide range of estimates with respect to the magnitude of losses. One reason,
suggested by Sparrow (1996), is that losses are not “systematically measured” (p. 86).
Sparrow (1996) discusses several challenges that make this type of measurement difficult;
firstly, any methodology for measurement would need to rely upon well-defined “outcome
classifications”, which would need to be based upon “objective, verifiable realities, none of
which precisely fit legal definitions of fraud” (Sparrow, 1996, p. 91). In addition, matters of
suspected fraudulent billing are often handled within the bounds of the industry and between
transactional parties; for example, monetary penalties or sanctions by payers and
credentialing entities may be imposed. However, in such cases, the fraudulent behavior is
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never reported to law enforcement agencies and no criminal investigation is undertaken and
as a consequence, these activities will never be included in the statistics. One suggested
reason for this internal handling of matters is the desire of the industry to protect its image
and reputation. Finally, there can be difficulties in separating fraud from other behaviors in
terms of measurement (Sparrow, 1996).
Most estimates of losses arising from fraudulent behavior center around the 10%
mark, in terms of losses as a percentage of total health care expenditures (Sparrow, 1996).
Liberman and Rolle (1998) estimated losses at a figure between $100 and $250 billion
annually, which would correspond to a range of 10 to 25 percent of total health care
expenditures. Liberman and Rolle (1998) further estimate that a typical American family
pays up to $1,400 yearly in additional costs due to fraud. Iglehart (2009) cites estimates by
the National Health Care Anti-Fraud Association (2009) which put fraud losses at
approximately $60 billion annually, but notes that these figures are considered conservative.
Specifically, in terms of the Medicaid program alone, losses are estimated at 10.5 percent, or
$18.6 billion yearly. While the exact monetary figure of losses arising from fraud is not and
cannot realistically be known, there is little doubt that the economic impacts are enormous
and, as such, warrant new approaches to achieving a solution.

SOCIAL CONSIDERATIONS
Implications of health care fraud extend beyond those of economics. Monetary losses
do not fully characterize its consequences, and further, its victims do not merely include
government programs, taxpayers and private insurance payers. In certain forms of fraud,
patients are put at significant risk of harm wherein they may become the subject unnecessary
medical treatments or procedures without their knowledge or understanding. The National
Health Care Anti-Fraud Association (2009) discusses the FBI’s work on cases involving
providers performing unnecessary procedures and distributing prescription medications in the
absence of any clinical basis. As an example, the FBI’s 2006 Jorge Martinez case is cited,
wherein Martinez was convicted on 56 charges arising from the death of patients due to his
inappropriate prescription of unnecessary drugs.
The majority of anti-fraud efforts over the last decade have focused on or
significantly involved providers. However, as of late, a growing concern for federal
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regulatory and law enforcement agencies is increasing involvement by organized crime

syndicates in health care fraud-related activities and enterprises (Iglehart, 2009). Hyman
(2001) suggests two reasons for this trend; first, that the potential monies to be gained exceed
that of other, more traditional, organized crime activities and, secondly, a reduced likelihood
of being caught. A CBS news article cites the Russian mafia’s involvement in health care
fraud, among other crimes including trade manipulation, cybercrime and excise tax scams
(CBS, 2000). A recent case targeting Russian immigrants involved payments to patients for
visiting a clinic, recruiting new patients and allowing the use of their Medicare numbers for
illegal purposes including submittal of false claims (Kennedy & Hays, 2010).
In terms of the social-moral environment surrounding the problem of fraud, Tennyson
(1997) studied data from a survey of 1,987 participants sponsored by the Insurance Research
Council in 1991. The intent of this survey was to assess consumer perspectives with respect
to a number of different issues relevant to the insurance industry; two of the questions related
to exaggeration of automobile insurance claims. Specifically, respondents were asked
whether they felt that it was acceptable to increase the amount of a claim to compensate for a
deductible, and in addition, whether they would consider the same acceptable to compensate
for monies paid towards past premiums. Results indicated that over 20% of respondents felt
that these behaviors were at least probably acceptable. Additional analysis by Tennyson
(1997) suggested that attitudes towards fraud are significantly tied to the consumer’s
perceptions of the insurance industry as well as institutional factors. Tennyson argues that
individuals’ perspectives and behaviors will be based upon, and representative of, larger
society’s outlook on insurance fraud. As such, peer network influences are important to
shaping individual attitudes. On the part of private (commercial) payers, fraud and the
resulting losses to the bottom line have often been addressed by premium increases, much in
the way that grocery stores raise prices to account for shoplifting losses. In this case, some
consumers may perceive disinterest by such payers which can shape patient perspectives, or
even create confusion in terms of what is and is not acceptable which would ultimately
contribute negatively to the growing problem. Tennyson (1997) recommends that anti-fraud
efforts incorporate initiatives to improve individual payers’ as well as the industry’s
reputation and image. The work of Barrese, Gardner and Thrower (1998), as cited by
Tennyson (2008), suggests that increased knowledge of the industry creates a more positive
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and more socially-favorable attitude on the part of the consumer toward insurance
companies.
While Tennyson’s (1997) work was based primarily in the context of automobile
insurance claim fraud, much of her findings and assessments are likely to be generally
applicable and representative of consumer attitudes towards fraudulent activity in other
insurance markets as well, including public and private-sector health care. Indeed, many
common elements are present between automobile and health insurance policies, such as
deductibles, co-pays, and coverage exclusions. Despite the fact that Tennyson’s (1997) study
focused on consumer-initiated fraud, and that in reality the majority of fraudulent activity
within the health care industry is perpetrated by providers (physicians and facilities), the
research findings are still useful to the objectives of this thesis. In terms of health care, it is
certainly arguable that patient attitudes would play a role both in the patient’s interest in the
problem domain as well as the patient’s willingness to report known fraud perpetrated by his
or her provider. The literature further suggests that increased education of consumers with
regard to the industry, as well as peer and network influences could be helpful.

COMMON FORMS OF FRAUD

According to the National Health Care Anti-Fraud Association (NHCAA), the most
commonly-committed forms of fraud include (a) billing for services not provided, (b)
misrepresentations and (c) intentionally rendering medically-unnecessary services (The top
five national health care fraud settlements, indictments and convictions, 2010, p. 8).
Major types of fraud, with estimated contribution of each to the larger problem
domain, is shown in Figure 5, using data compiled by the Health Insurance Association of
America, Blue Cross Blue Shield and the NHCAA (Datawatch, 2000). As Figure 5 shows,
billing for services not rendered is estimated to account for 34% of fraudulent activity.
Upcoding is estimated to account for 22% of occurrences of fraud; upcoding can be
considered a lesser form of billing for services not rendered and also as a misrepresentation,
wherein bills are submitted for medical services using a procedure code of unnecessarily-
high specificity that does not reflect the most accurate nature and/or extent of services
performed. Pharmacy-related fraud is estimated to account for 35% of the problem; such
 14

Figure 5. Estimated contribution to health care fraud, by type of behavior.

Source: Datawatch. (2000). Health Insurance Fraud Busters. Business and
Health, 18, 64.

pharmacy fraud includes patient fraudulent behaviors (e.g. drug-seeking) and provider
fraudulent behaviors (e.g. prescribing unnecessary or otherwise inappropriate medications).

Billing for Services Not Provided

Submittal of charges for services or supplies never performed or provided is self-
explanatory. In its simplest and most common form, fraud committed in this manner may
involve the addition of one or more related procedure codes to billing statements submitted to
the insurance payer for a patient that the provider saw. A less common, but still prevalent,
form of abuse is the submittal of charges for patients whom never had an encounter with the
provider. In one noteworthy case, a Miami-area individual was arrested for submitting over
$55 million in fraudulent claims to Medicare for HIV and cancer-related procedures; the bills
were submitted from phantom clinics and the patients for whom services were being billed
had never visited these clinics and/or had any contact with the submitter (The top five
national health care fraud settlements, indictments and convictions, 2010, p. 8).
The best defense against the above type of fraud would be a thorough review by
consumers of all documents received from payers (this would include the federal
government, in such cases where the patient is covered by a Medicare plan). In terms of
scenarios where the patient did in fact visit his or her provider, but where services billed
exceed that of the services actually rendered, a review of the explanation of benefits (EOB)
 15

by the patient should, theoretically, help to identify any such issues. In a study conducted by
Sparrow (1996) and funded by the National Institute of Justice, eight entities were
interviewed about the problem of health care fraud. The entities consisted of regulatory units,
private payers of differing sizes, and several Medicare contractors. A number of persons
whom were interviewed felt confident that EOBs help to protect against fraud perpetrated by
providers. However, according to Sparrow (1996), there are several factors that prevent
EOBs from being a useful tool in combating the problem. First, EOBs are not mailed out to
beneficiaries on a consistent basis for a variety of reasons, both with respect to the Medicare
and Medicaid programs. Secondly, they are not used for home health services, despite the
fact that this type of service has been one of the most significant sources of fraud over the
last 30 years. In addition, some consumers do not take the time to read them, since these are
not bills requiring payment; they are only a listing of services provided. Another key concern
cited by Sparrow is that patients "cannot decipher the strange, computer-generated forms"
(Sparrow, 1996, p. 90).
This thesis argues that issues surrounding patients’ ability to read and understand
correspondence such as EOB documents, due to terminological barriers, are a fundamental
limiter of effective patient involvement in combating health care fraud. In light of this, the
subject will be explored directly within the study undertaken in, and conclusions set forth by,
this thesis; in addition, the topics of terminology and vocabulary will be discussed in later
portions of this chapter.

Misrepresentations
In cases of misrepresentations, such conduct may involve exaggerating the type of
services and/or treatments performed (generally referred to as “upcoding”), manipulating
service dates, exaggerating the patient’s condition to justify submitting charges for more
complex procedures, and/or misrepresenting the provider’s or patient’s identity. One
landmark case involved such misrepresentation of identity, wherein an individual operated 21
durable medical equipment (DME) companies in the Miami, Florida area. Using these DME
companies, the individual defrauded the Medicare program of approximately $179 million by
submitting fraudulent bills to CMS using stolen Medicare provider identification numbers. In
 16

this case, the perpetrator was sentenced to 14 years in prison and a fine of $35 million (The
top five national health care fraud settlements, indictments and convictions, 2010, p. 8).

Rendering of Medically-Unnecessary Services

When a provider renders medically-unnecessary services and treatments, this is
considered both a form of abuse as well as fraud; while the provider’s billed charges may
reflect services actually performed, the services should not have been performed in the first
place and may, depending on the nature of procedures performed, have unnecessarily placed
the patient at an increased risk of harm.

Upcoding, Unbundling and Related Billing Practices

Upcoding refers to the inflation of a billed charge, by utilizing a code with a higher
degree of specificity and/or complexity, when such use is inappropriate or otherwise not
advised. One example of upcoding would be the use of a procedure code describing a
complex office visit (lasting over one hour) when the patient was only in the office for 15
minutes. Another example might include the use of the generic version of an injectible drug
during a patient visit, but where the final bill submitted to the patient’s insurance carrier
specifies that a brand name (and thus, more expensive) drug was administered by the doctor.
Unbundling is a practice in which a procedure (usually a surgery or other multi-faceted
procedure and/or otherwise complex) has available a comprehensive billing code; however,
the provider bills for each component of the operation separately in order to earn a higher
reimbursement from the insurance payer. Certain procedures are considered comprehensive
because the performance of such procedures either require the other steps to be taken as a
matter of course, or in order to achieve the ultimate goal, and/or one or more of the other
components is viewed to be a logical extension of the other component(s).

PUBLIC SECTOR ATTEMPTS AT COMBATING THE

PROBLEM
The Health Insurance Portability and Privacy Act (1996), commonly known as
HIPAA, was enacted by the 104th Congress in order to create reforms related to several
aspects of health care delivery. More specifically, areas in which these reforms are applicable
include, but are not limited to, the following: improved portability and continuity of health
 17

insurance coverage, waste and abuse with respect to health insurance and health care
delivery, medical savings accounts, long-term care accessibility, and simplification of health
insurance administration. One of the primary reasons that legislation dealing with issues such
that are covered by HIPAA was needed was the increasingly electronic nature of the
healthcare environment; such a technological evolution brings with it a number of benefits,
as well as, concerns. In electronic environments, protecting privacy can be considerably
difficult; further, patients had become increasingly concerned about privacy matters related
to their health information, particularly in terms of distribution control.
In order to partially facilitate the accomplishment of several key components of its
legislation, HIPAA imposes a number of technical and data-related standards governing the
exchange of information between parties to health care transactions. These standards include
ANSI (American National Standards Institute) electronic document standards developed by
the X12 subcommittee to be used for a myriad of scenarios such as payment of health care
claims, exchange of claim status, eligibility requests and remittance advice. In addition, new
provider identification standards have been put in place, including NPI (National Provider
Identification) numbers which facilitate easier tracking of provider activities. Prior to NPI
assignments, provider identification (with the exception of DEA prescriber identification
numbers) was managed at the state, rather than federal, level.
In terms of protected health information (PHI), HIPAA legislation has significant
implications for data security, authorized uses and privacy in terms of accessibility of patient
health data. Several modifications have been made to the HIPAA Privacy Rule since its first
version. The most recent version of the Privacy Rule (last modified on August 14, 2002)
seeks to clarify certain components, wherein language and ambiguity has created unintended
consequences that have hindered legitimate usage and exchange of data. Feedback received
from insurance payers, hospitals, physicians and other entities involved in healthcare
transactions made clear that earlier iterations of HIPAA privacy legislation presented a
number of challenges in effective coordination and communications among healthcare
industry parties. Rule makers recognized these concerns and made revisions dealing
specifically with exchange of information for coordination of benefits, payment and referral
purposes. Consequently, adjustments were made to language related to disclosure safeguards,
as well as data collection and maintenance.
 18

A key element to increasing effectiveness of anti-fraud efforts, as well as more

general public health research, is data accessibility. More changes must be made in order to
allow industry entities to feel more comfortable with data exchange and distribution. Even
with its most current revision, the HIPAA privacy rule continues to hamper efforts to utilize
health data for important purposes that are significant for society and the nation’s economy.
The federal False Claims Act was passed by Congress in 1863 as a means in which to
increase accountability of defense contractors. At this time, the federal government found
itself faced with significant losses due to fraud perpetrated by entities promising to deliver or
otherwise provide equipment and provisions to the Union army. While defense contractor
fraud was the government’s concern at the time of the introduction and passage of this
legislation, the act was written in such a way as it would be applicable to any and all frauds
committed against the government. Original penalties for false claims included a $2,000 fine
and twice the amount of actual damages per false claim (Meador & Warren, 1998).
A number of modifications have been made to the original act since its initial passing;
however, the spirit of the act has remained consistent. An individual is liable under the False
Claims Act in any case where he or she has “knowingly presenting to the United States
government any false or fraudulent claim for payment”. It is important to note that, within
the framework of this act, “knowingly” is defined to include both recklessness and deliberate
ignorance; no burden is imposed upon on the prosecution to demonstrate or prove actual
intent to commit fraud. In addition, any false statements included in support of a claim are
considered to be false claims in and of themselves (Ryan, 1995).
One of the most interesting aspects of the original act of 1863 was a provision made
for individuals to personally prosecute submitters of false claims; these are referred to as qui
tam actions. If the submitter was found to be liable under the False Claims Act, the
prosecuting individual was entitled to receive up to fifty percent of any monetary damages
awarded at trial. Originally, the individual prosecuting the defendant had the burden of
paying all costs associated with the lawsuit; however, the federal government was restricted
from taking over the action (Meador & Warren, 1998). Although some modifications have
been made to statute, the privileges afforded by this provision are still available at present; a
significant and growing number of cases have been prosecuted under this method over the
last ten years. A number of high profile cases related to health care fraud have been brought
 19

by both individual whistleblowers as well as groups, under the qui tam provisions of the
False Claims Act. One of the largest cases involved Tenet Healthcare Corporation, a hospital
operator. In this case, Tenet settled and agreed to pay approximately $900 million to the
federal government for submittal of fraudulent claims to Medicare as well as other federally-
sponsored or subsidized health care programs. As a result of another qui tam action, $73
million was recovered from Beth Israel Medical Center, based on alleged misrepresentation
of operating costs and improper claiming of a number of non-reimbursable costs.
Qui tam actions are discussed further in the following section, since while the
provision to bring such actions was created by government legislation, the bringing of such
an action in practice falls within the purview of private-sector and consumer efforts.

PRIVATE SECTOR ATTEMPTS AT COMBATING THE

PROBLEM
As was just discussed, the False Claim Act provides for qui tam suits, wherein private
individuals and groups may bring actions against suspected perpetrators of most any type of
fraud, including fraud related to health care payment and delivery. As stated by Boese
(1999), “one of the biggest hotbeds of qui tam litigation is likely to be the waiting room of a
managed care provider” (Boese, 1999, p. 2). Historically, the majority of qui tam actions
have been brought by current and former employees of organizations within the health care
industry. However, patients will represent the plaintiff role in a larger percentage of these
cases as time goes on. Under managed care programs, it is suggested that greater
dissatisfaction is observed among the patient population. In making his case, Boese (1999)
presents key distinctions between managed care and fee-for-service forms of health care.
Patients covered under fee-for-service programs can select any provider, while managed care
patients have much less freedom in this regard. If a fee-for-service patient is unhappy with
services being rendered by his or her provider, the patient can simply go elsewhere. In this
case, private and public payers, as well as taxpayers, are the ones most affected by fraud. In
managed care programs, however, the patient herself suffers more directly because fraud in
this context will also usually cheat the enrollee out of necessary services.
The NHCAA (National Healthcare Anti-Fraud Association) currently sponsors a
closed, web-based system for communications between government entities and payers. This
system is managed and hosted by Lexis Nexis and is only available to certain user types with
 20

current, paid memberships in the NHCAA. This system allows sharing of information
between law enforcement, regulatory agencies and payer compliance officers, including case
details, trends in the ever-changing fraud environment and alerts. The most obvious
limitation of this system is the exclusion of a number of relevant parties; most significantly,
patients (consumers).

Challenges in Public-Private Sector Collaboration

Testimony by Sheri Farrar, Executive Director of the Special Investigations
Department of HCSC, highlights the importance of information sharing as a component of
reducing the problem of health care fraud in addition to revealing difficult challenges in
information exchange between the private and public sector. According to Farrar, keeping
pace with perpetrators of fraud requires ongoing collaboration between diverse parties,
including law enforcement, regulators and representatives of the private sector. One
successful example of collaboration cited by Farrar (Criminal Prosecution as a Deterrent to
Health Care Fraud, 2009) is a meeting held shortly before her testimony, in which
representatives of the FBI, CMS, Health and Human Services and others came together to
discuss strategies and outcomes of recent cases.
Despite successes such as the meeting cited above, it is made clear in further
testimony that in many instances, collaboration surrounding health care fraud involves
unreciprocated information flow from insurance payers to government entities. Reasons cited
for issues of sharing include ignorance by government representatives as to what authority
they possess to release such information, despite guidelines created and distributed by the
Justice Department and DHHS. Additionally, when information is shared, details
surrounding the perpetrators’ strategies and facts related to the investigations should be
included (Criminal Prosecution as a Deterrent to Health Care Fraud, 2009).
Providing more complete and comprehensive information to the private sector,
especially with respect to Farrar’s (Criminal Prosecution as a Deterrent to Health Care Fraud,
2009) recommendations above, would allow payers to more effectively examine trends and
patterns in their own claims data and provider networks. Such useful exchange would
essentially result in a payer’s capturing of new knowledge; once internalized, this knowledge
 21

would assist the entity in monitoring and investigating activities on its own while relying less
upon government and regulatory resources.

Commercial Fraud Detection Tools and

Methodologies
Current information systems in use by the health care industry for fraud detection
purposes primarily consist of decision support systems for pre and post-adjudication claims
analysis. These systems are rules-based, and such rules are generally defined and
implemented into the system programmatically based on government guidelines and
industry-generated best practices for billing. Examples of such systems include, but are not
limited to, those created by PCG Software, HCI and Fair Isaac. Software developed by these
vendors are representative of the current market in terms of available products; these tools
analyze claims within a payer’s management and adjudication systems. A major weakness of
such systems is that all analysis is done at or after the time of adjudication and payment.
Many fraudulent claims slip through undetected.
As stated in the introduction, this thesis argues that such systems, while useful to a
degree, are insufficient in their ability to effectively combat the scope of problems present in
the current environment of fraud, waste and abuse. These systems rely upon rules identified
by one source group (industry “experts”), and as such, one categorical source of knowledge.
Lessons learned from the knowledge management discipline reveal the importance of
identifying, internalizing and leveraging data and information from all relevant sources. The
absence of patient tacit and implicit knowledge is one glaring weakness in the sole reliance
upon a rules-based decision support system for fraud detection. Rules-based DSS and expert
systems will be further addressed later in the paper, as well as within the study conclusions.
The paper now turns its attention from the health care industry and specific problem
domain to topics from the literature directly related to knowledge management. This thesis
argues that KM, while traditionally employed as part of an organization’s internal
competitive strategy, can serve an equally-compelling purpose beyond the organizational
context by an application of the discipline’s conceptual lessons learned and best practices to
other frameworks involving connections, relationships and collaboration between individuals
and groups towards a narrow, common goal.
 22

This paper examines and studies patient barriers to participation in health care anti-
fraud activities, particularly in terms of collaborative knowledge exchange efforts. The
knowledge management concepts discussed in this chapter, as well as concepts described in
the chapters beyond the analysis of study results, are applied to understanding of the problem
and to the development of a proposed model for a KM system that attempts to overcome the
aforementioned barriers. Such conceptual applications will include, but not be limited to, the
following:
 challenges associated with vocabulary of diverse parties, as well as shared context
 patients as a valuable, and viable, source of tacit and implicit knowledge
 ways in which knowledge is created by, and transferred from, patients to other
patients as well as other health care stakeholders, applying Nonaka’s SECI model of
knowledge conversion
 identification and leverage of human knowledge sources, including patients, as a
critical success factor
 parallels between communities of practice and distributed collaborative networks
 limitations and impracticalities of rules-based DSS systems as a complete solution to
anti-fraud strategic planning

THE CONCEPT OF KNOWLEDGE

Liebowitz (1999) cites a number of proposed definitions of ‘knowledge’. These
include, but are not limited to, “organized information applicable to problem solving”,
“information that has been organized to make it understandable”, and “truths and beliefs,
perspectives and concepts, judgments and expectations, methodologies and know-how”.
Further, Liebowitz (1999) describes two different dimensions of knowledge, as storage
media (where the knowledge resides) and accessibility (tacit, implicit and explicit). Hislop
(2005) helps to distinguish knowledge from information and data, defining knowledge as
“data or information with a further layer of intellectual analysis added, where it is interpreted,
meaning is attached, and is structured and linked with existing systems of beliefs and bodies
of knowledge” (Hislop, 2005, p. 15).
As explained by Nonaka (1994), knowledge consists of two types, tacit and explicit,
whereby tacit knowledge is personalized and difficult to articulate and therefore transfer to
others, and explicit knowledge is codified and can be exchanged in a formal and systematic
manner. Beckman (1999) extends the classification of knowledge and proposes implicit
 23

knowledge as a third dimension. Beckman’s (1999) definition of implicit knowledge is

similar to accepted definitions and understanding of tacit knowledge, but distinguished from
the tacit in that implicit knowledge is “tacit in form, but is accessible through querying and
discussion” (Haggie & Kingston, 2003). Nonaka cites the concept of mental models as
proposed by Johnson-Laird (1983) and calls attention to the role of such mental models as a
cognitive element of tacit knowledge. Jennex (2005) considers mental models in terms of
knowledge formation in the framework of culture, and further, proposes common context of
understanding as the combination of culture and context.

DEFINITIONS AND OBJECTIVES OF KNOWLEDGE

MANAGEMENT
The discipline of knowledge management (KM) has been defined in a number of
ways since the time of its formal recognition in 1991. According to Bukowitz and Williams
(1999), knowledge management is “the process by which the organization generates wealth
from its intellectual or knowledge-based assets” (Bukowitz & Williams, 1999, p. 2). Jennex
(2005) defines the discipline as “the process of selectively applying knowledge from
previous experiences of decision-making to current and future decision-making activities” (p.
viii). According to Buono and Poulfelt (2005), KM embodies “the ways in which
organizations capture, process, share and use information” (Buono & Poulfelt, 2005, p. ix).
Cofino et al. (2003) discuss the concept of getting “the right knowledge to the right people at
the right time so they can make the best decision” (Cofino et al., 2003, p. 789). Chatti, Jarke,
and Frosch-Wilke (2007) cite popular concepts and research foci including true belief,
context, purpose and target group, and additionally, classification of knowledge. Ahmed,
Kok, & Loh (2002) propose that knowledge management is “the coming together of
organizational processes, information processing technologies, organizational strategies and
culture for the enhanced management and leverage of human knowledge” (Ahmed et al.,
2002, p. 12).
Chatti et al. (2007) propose a more specific definition and objective of knowledge
management that emphasizes knowledge quality; it is suggested that one key to KM
effectiveness is the connection of people to quality knowledge. This paper recognizes the
value of considering quality and extends this objective to specify that people (when in the
role of KMS users) must be connected with knowledge that is not only of high quality
 24

(accurate and comprehensive), but that also carries a high degree of usability within the
framework of the user’s own context. For purposes of this thesis, this means that a user,
based upon his or her individual experiences, background and aptitudes, must be able to
effectively understand, internalize and apply information and knowledge. According to
Jennex (2005), effective KM requires successful capture and reuse. In order to accomplish
this, several key goals must be met with respect to the processing and leverage of knowledge:
(a) identification, (b) acquiring, (c) sharing, (d) application to relevant scenarios and
situations, (e) determining effectiveness of use, and (f) adjusting usage in order to increase
the knowledge’s effectiveness.
Despite what are numerous, but often subtle, differences and interpretations
surrounding a formal definition of knowledge management, its purpose is essentially to
encourage the view of information and knowledge as assets. Above all else, the knowledge
management discipline recognizes the importance and value of knowledge as intellectual and
human capital. As such, the purpose of traditional KM has always been one of helping
organizations to capture and leverage knowledge in its various forms, in order to increase
effectiveness of the organization and to gain new, or build upon existing, competitive
advantages.
In the framework of patient participation in anti-fraud initiatives, common context of
understanding is a critical component which must be considered in the study. When speaking
of barriers to involvement, it is hypothesized that lack of understanding creates an unleveled
playing field in which an average patient is either uncomfortable in, or simply lacks the
capability in, serving as an effective participant and collaborator. Certainly, culture and
context can be vividly different among different demographical and occupational
classifications within the population; a physician with a number of years of training and
education who is intimately familiar with medical terminology and comfortable with
computers exists at an extreme distance along the continuum from an elderly patient who has
had no exposure to industry terminology and is uncomfortable with technology in general.
Between a lack of relevant experience, and biases and particular heuristics developed over a
lifetime, our example patient would likely speak an entirely different language in terms of
describing a healthcare encounter, illness or other related event than her care provider.
 25

THE GROWING ROLE OF KNOWLEDGE MANAGEMENT

IN HEALTH CARE INDUSTRY APPLICATIONS
The health care industry faces fundamental challenges that can be appropriately
addressed through the leveraging and applying of KM principles. Capture of clinical
knowledge, globalization with evidence-based medicine, and potential liabilities due to lack
of necessary knowledge at point of care are three major problems faced by the industry at the
present time (Guptill, 2005). Guptill (2005) identifies five significant areas of opportunity for
the effective application of KM to health care; these areas are communities of practice,
content management, knowledge transfer, performance tracking and finally, technology and
support infrastructure. Communities of practice (to be discussed in further detail in a later
chapter of the paper), as Guptill suggests, can be useful for, among other things, connecting
people with similar roles or business issues within a hospital, or even to facilitate
collaboration and sharing surrounding a specific clinical issue. In terms of knowledge
transfer applications, efforts have been made by the Institute for Healthcare Improvement to
implement a collaborative system for connecting hospitals and helping them to share
knowledge related to emerging and innovative clinical practices. Guptill (2005) discusses the
manner in which clinical practices are shared inside of hospitals and how this relates to the
hospitals’ relationships with payers, patients and doctors.
Bose (2002) conducted research with the objective of developing a model for a health
care KM system that would assist information technology professionals in planning and
development of support systems for health care knowledge management within those
professionals’ organizations. The paper presents a system to accomplish meet several
requirements; one is that of improving information access among diverse parties to health
care operations in order to reduce costs. Additional objectives include building a community
of practice consisting of members that effectively represent domain stakeholders, and
facilitating more effective self-care. With respect to forming a CoP, it should be noted that
Bose (2002) specifically includes care recipients (patients) into his proposed list of
represented groups. As justification for his research, Bose (2002) cites work by Jadad,
Haynes, Hunt and Browman (2000), remarking that the health care industry is evolving into
an increasingly knowledge-based community that is more connected and further, that health
 26

care’s success as an industry is dependent upon effective exchange of information and

knowledge within the organization and between parties.
According to Bose (2002), a KM system appropriately identifies target users and their
respective needs. Such systems should account for the requirements of clinicians,
administrators and patients. In terms of patient requirements, data security and privacy is a
prime concern. Obtaining or developing KM support systems and capabilities facilitates
knowledge exchange between what would have been “previously disparate knowledge
repositories belonging to different organizational units” (Bose, 2002; Broadbent & Weill,
1997; Liebowitz, 1999; Maurer & Holz, 1998). In his model of a health care KM system,
Bose (2002) presents eight necessary components to a successful implementation. These
components consist of:
 Presentation (user interface)
 Personalization (filtering and intelligent agents)
 Collaboration (workflow and discussion forums)
 Process (clinical, financial and administrative)
 Publishing and Distribution (authoring, push technology and notification)
 Integrated Search (engines, data mining and filtering)
 Categorization (ontology)
 Integration (indexing, knowledge repository and document management)
Work by Jadad et al. (2000) involves an examination of the relationship between the Internet
and clinical evidence-based decisions. Jadad et al. (2000) remark that the internet is posing
new challenges for users due to difficulties in locating, processing and utilizing information
among an enormous quantity of data, some of which is of questionable accuracy and
relevance. Further, it is noted that disagreements may arise between decision-makers based
on differing information. It is proposed that in order for both the internet (in a health care
context) and evidence-based medicine to realize their maximum impact, “a powerful and
efficient synergy must develop between them” (Jadad et al., 2000, p. 1). Jadad et al. (2000)
believe that the internet can reduce costs and improve access to quality information, and in
addition, that knowledge surrounding evidence-based medicine could help to better clarify
the internet’s role in health care, enabling solutions to problems and identification of new
opportunities for its effective use. They note that the internet has already enabled a number of
 27

opportunities for clinical benefit, but suggest that bandwidth increases will play the key role
in further developments. Different types of information and knowledge will be exchanged in
combination via innovative methods of communication and transfer (Jadad et al., 2000).
Additional bandwidth, in combination with current and coming wireless and computing
portability advances, should provide the capabilities for better sharing and utilization of
knowledge by diverse groups whom represented various parties within the health care
industry, without consideration to geographic and other boundaries (Jadad et al., 2000).
Bose (2002) proposes a compelling and architecturally-sound model for a health care
knowledge management system. The components of this model could well support effective
KM applications surrounding the study of fraud; however, any significant discussion of these
possibilities is visibly absent. In addition, no detailed consideration is undertaken (or at least
presented) with respect to terminological and vocabulary differences among the parties; this
would likely fall into the ‘Categorization’ component, but in any case, deserves further
attention.
The majority of KM-related research and scholarly undertakings have thus far
concerned themselves with electronic patient records, generalized hospital systems, and
clinical point-of-care decision support systems. Very little work has been done in academia
towards solutions to the problem of health care fraud due to its complexities. The literature
review did not uncover any existing literature describing a true knowledge management-
based approach to, and analysis of, the specific problem of health care fraud.

COMMUNITIES OF PRACTICE
In simple terms, a community of practice (CoP) can be defined as a group of
individuals sharing a mutual interest, profession or skill. While such collectives may be
formed intentionally and purposefully (usually with the specific objective of knowledge
creation and sharing), these communities often come into existence as a natural consequence
of social interactions surrounding members’ common interest in their particular domain.
Such interactions may take the form of sharing among, and learning from, members of a
department or division within an organization; they may also occur in online niche social
networking environments or among individuals involved with a particular professional or
trade organization.
 28

Considerable research in this area has been done by Etienne Wenger; in terms of
structure, Wenger (1998) proposes three key components that define a community of
practice. These consist of joint enterprise, mutual engagement and shared repertoire,
respectively. Joint enterprise refers to the negotiated purpose of the group. Mutual
engagement serves to retain strong connections and relationships between community
members. Shared repertoire is the embodiment of knowledge and related resources created
and collectively owned by the group, including documents and vocabulary (Wenger, 1998).
Wenger (1998) draws important distinctions between communities of practice and
other collectives, based on key differences surrounding concepts of self-definition,
establishment of boundaries and the nature of their existence. In terms of boundaries, a
community of practice can be characterized by its considerable flexibility; group membership
is not restricted in the same way as an organization’s functional unit and is defined instead by
interest and participation. Different members with varying levels of experience and level of
participation introduce new insights to the group. Further, these communities define
themselves by knowledge instead of by task. Compared to a simple network, these groups
have a clear purpose which extends beyond mere relationships (Wenger, 1998).
There are numerous examples of successful communities of practice, across diverse
disciplines and both inside and outside of business organizations. One of the most successful
CoP stories takes place at Xerox Palo Alto Research Center. In this case, Julian Orr (a
researcher at this center) studied the activities of Xerox technical service representatives and
found that representatives often deviated from the organization’s formalized processes and
procedures when troubleshooting machines at client locations. Troubleshooting and repair of
technological equipment involves many variables and successful resolution of such problems
requires the ability to leverage and intelligently apply past experience to the process (Brown
& Duguid, 2000). Ultimately, among Xerox representatives, a culture was developed and
encouraged wherein knowledge was shared among the members of the unit, resulting in more
effective on-site repair services and, as a consequence, increased customer satisfaction.
Another intriguing example of a successful CoP is a group established by Green For All,
created to connect practitioners in the field of environmentally-sensitive workforce
development. The group operates online discussion forums, hosts a myriad of resources and
documents, as well as organizing conference calls. In the educational arena, Columbia
 29

University maintains a repository which facilitates sharing of, and collaboration surrounding,
academic research papers and other shared resources. This is an interesting example due to
the fact that it highlights the potential for a CoP to develop by way of a natural evolution
created by individual’s activities. In this case, the nature of and dynamics surrounding how
this system was utilized by various members of the university population actually, in essence,
created a community of practice (Cocciolo, Chae, & Natriello, 2007).
Placing the concepts surrounding communities of practice into the framework of the
knowledge management discipline, these groups constitute a valuable source of information
for knowledge workers. CoPs facilitate efficient and effective exchange of knowledge
between members, in terms of sharing of experiences and, more importantly, conveying (thus
encouraging) the application of best practices to whatever domain is involved. Communities
of practice can be, and often are, an integral component to the success of an organization’s
broader knowledge management strategy. Since the discipline of KM primarily concerns
itself with capturing, organizing and distributing knowledge (Kellogg & Erickson, 2001) to
the right individuals at the right time, these groups serve as an effective and vital conduit for
information exchange. A community of practice supports KM activities by serving as a key
source of content and context which can be codified and utilized in meaningful and
productive ways by the community’s members.
Successful initiation, cultivation and ongoing support of a CoP are necessities for the
group to thrive; active monitoring and promotion of the group help to achieve increased
effectiveness in knowledge management (Collison, 2010). Kimble (2010) notes that these
communities illustrate a compelling example of the relationship between KM and distributed
collaborative work; prior research has shown that a CoP can operate successfully both for
tacit knowledge exchange as well as document sharing. In addition, Wenger (1998) puts forth
a view of a CoP not necessarily as a single organization itself, but rather as a connection of
communities of practice that are related to one another for the purpose of knowledge transfer.

KNOWLEDGE MANAGEMENT SYSTEMS: PLANNING AND

CONSIDERATIONS
One of the most significant challenges in effectively combining available knowledge
from its many, often diverse, sources relates to differences in vocabulary. Individuals from
different knowledge areas may use different terminology and as a result, often experience
 30

difficulties in communicating with one another. Despite such variations in terminology, it is

often found that the same concepts are meant (Liebowitz, 1999). Along the same lines, Hahn
and Subramani (2000) explore different KM system implementations and find that different
implementations impose different burdens on system users. Specifically, systems using an a
priori structure are most useful for the members of a narrow target community, but this same
structure poses challenges for other users in locating relevant content due to lack of access to
local vocabulary. With loosely-structured knowledge sources, issues and considerations
surrounding domain and content diversity become exacerbated by this lack of shared
vocabulary (Hahn & Subramani, 2000).
In the scope of planning, developing and implementing a knowledge management
system, the concept of human intellectual capital is a significant success factor in terms of
outcomes, with respect to the system’s ability to perform its objective of effective knowledge
capture. A business organization, or any entity building such a system, must recognize the
potential of acquiring useful knowledge (of both the tacit and explicit varieties) by thoughtful
identification of all knowledge sources. In identifying potential sources of knowledge,
processes for learning need to be given serious consideration; evaluation must be taken, and
subsequent questions asked, with respect to user representation. Concerns should be raised
when individuals, or categories of individuals, are not involved or engaged with the KM
system. Thought should be given to how the involvement of those individuals or group(s)
could be included and what effects such involvement would have upon content and
knowledge flow (Fahey & Prusak, 1998).

KM System Success Factors

Jennex and Olfman (2006) have developed a set of success factors for KM system
implementations based upon earlier work by DeLone & McLean. In their article, Jennex and
Olfman (2006) applied a combination of the DeLone and McLean IS Success Model and
additional KM research, to evolve their own OMS Success Model (Jennex & Olfman, 2006)
into a KM Success Model. Specific components of this model and relevant takeaways will be
used as theoretical bases for a proposed KM system model (presented in a subsequent chapter
of this paper) that seeks to address key issues within the problem domain described by this
thesis.
 31

The key dimensions of the Jennex and Olfman (2006) model include System Quality,
Knowledge Quality, Service Quality, Intent to Use/Perceived Benefits and User Satisfaction.
The system quality component includes several considerations; these are essentially technical
infrastructure (including competencies), how knowledge is computerized and integrated with
the organization’s processes, and finally, effectiveness of system implementation in terms of
knowledge accessibility (for example, ease of search). Knowledge quality is defined as a
combination of KM strategy (identification of knowledge users/sources of knowledge),
relevancy (through accuracy and appropriate context) and timeliness of knowledge. Service
quality within a KM system is essentially the result of comprehensive user support from both
management and IT (technical support staff). User satisfaction, intent to use and perceived
benefits are closely related, and ultimately reflect the sentiment of users in terms of how well
the system assists in locating and exchanging useful knowledge.
Concerning measures related to system use, Jennex and Olfman (2006) discuss a key
change in DeLone and McLean’s 1992 model and the 2003 model, wherein actual use was
replaced with intent to use, as a KMS success factor. Jennex and Olfman (2006) support the
decision by DeLone and McLean to make this change, pointing out that in certain cases, a
KM system may be used much less frequently than other KM systems, yet this less-frequent
use may be considerably more important (depending upon the type of knowledge, how such
knowledge is being used and its impact on other organizational processes).

EVOLVING FRAMEWORK OF THE KM DISCIPLINE

In a recent CIO Magazine article, Spanbauer (2006) discusses a concept that he calls
“Knowledge Management 2.0” and explains why more traditional enterprise KM software
and systems have not caught on to the expected degree, given the enormous benefits that KM
can offer. It is argued that the primary reason is that users hate these systems, due to the fact
that it takes users more work and actually takes away time from doing normal work in order
to access and register documents. Spanbauer (2006) points to indicators suggesting that by
2010, less than ten percent of the world’s largest organizations would have specific KM
programs, but almost all of them will apply concepts and techniques of the discipline. Newer
products have emerged that build upon conceptual features and functionality of familiar Web
2.0 concepts, such as blogging and file sharing. These products have included offerings in
 32

such areas as networked desktop search and document collaboration tools with modification
subscription support.
One of the biggest concerns that affect any applications surrounding data sharing in
the health care industry are patient privacy and control of data. Tacit’s (purchased by Oracle
in 2008) Illumio software product, while no longer available as of the time of this thesis,
pioneered new ways of sharing and searching for distributed information across users and
departments within organizations. Using this product, corporate users could perform searches
on their local machines, with the application software performing searches on other users’
machines. If relevant results were found, the results could be returned to the originating-
query user upon permission for release of the data by the target machine. This architecture
and methodology could well be applied to a distributed knowledge management system to
allow consumers to share patient health information with other users and components of the
larger system, giving users granular security control over released data.

BARRIERS TO COLLABORATIVE PARTICIPATION

This paper proposes a number of potential barriers to participation by patients in any
health care-related knowledge exchange system, whether an online forum for domain-
specific collaboration, a health and wellness social network, or any other form of distributed
virtual community. Key potential barriers discussed herein are (a) differences in terminology
usage and understanding, (b) concerns surrounding data sharing, privacy and security, (c)
exclusions of patients as a stakeholder and valuable source of knowledge, (d) lack of
awareness or interest in the problem domain, and (e) level of technical sophistication. This
paper hypothesizes that terminological challenges represent the most significant barrier to
participation and, therefore, considers this matter first.

Differences in Terminology Usage and Understanding

One of the most significant challenges in effectively combining available knowledge
from its many and often diverse sources arises from differences in vocabulary. Individuals of
different backgrounds and experience levels may use different terminology and as a result,
often experience difficulties in communicating with one another. Such use of inconsistent
vocabulary during knowledge exchange interactions may negatively impact the process and,
ultimately, the outcome of any collaborative effort (Chen, 2002), if any collaboration can
 33

even occur at all. According to Fahey and Prusak (1998), a lack of shared vocabulary is one
of the key inhibitors to the creation, sharing and use of knowledge. When such knowledge
exchange is done through a repository, knowledge base or any other KM system,
terminological inconsistencies may further hinder certain users’ ability to perform effective
database queries (Chen, 2002).
Differences in terminology may reflect lack of understanding of the domain, or
simply differences in terminological preferences by the parties. In either case, and despite
such variations in terminology, it is often found that the same concepts are meant (Liebowitz
& Wilcox, 1997). In general, the parties truly believe that they are articulating and expressing
the synonymous content and meaning. In the context of health care KM systems, which
encompass distributed collaboration networks, social networks for connecting patients
struggling with the same diseases, clinical evidence-based systems and a number of other
types, such confusion could have consequences ranging from system ineffectiveness, up to
and including physical dangers, depending on the type and objective of the system.
Hahn and Subramani (2000) explore implications of different KM system implementations
and find that different implementations impose different and corresponding burdens on
system users. Specifically, Hahn and Subramani (2000) find that systems employing an a
priori approach to structure are most useful for the members of a narrow target community;
however, this same structure poses challenges for other users in locating relevant content due
to lack of access to local vocabulary. With loosely-structured knowledge sources, issues and
considerations surrounding domain and content diversity become exacerbated by this lack of
shared vocabulary. Further, it is suggested that “the strength of weak ties need to be balanced
against the downside of information overload and incongruent vocabularies.” (Hahn &
Subramani, 2000, p. 306)
Having now established the challenges presented to communications and knowledge
exchange in the face of differing vocabularies among diverse participants, this chapter moves
into an examination of the literature with respect to studies conducted in order to assess such
differences in use and understanding of terminology within the health care context.
In order to assess and evaluate the degree to which patient understanding of medical
terminology had changed since the time of earlier and similar studies, Thompson and Pledger
(1993) conducted research wherein 224 participants were asked to define a list of 50 medical
 34

terms. These terms were selected by doctors and other care workers. Thompson and Pledger
(1993) began their work with the assumption that understanding of terminology by patients
would have increased since the time of the previous study, due to heightened interest in and
awareness of health and wellness. As rationalization for their study, Thompson and Pledger
(1993) assert that a common understanding is crucial for both doctor and patient and further,
that a more current evaluation of terminological understanding is necessary due to the
increasing exposure of consumers to medical terms through media channels.
In conducting the study, a list of 173 medical terms was generated, from several
sources including words used in earlier investigations. From this set, a group of doctors
collaboratively determined which words to keep, based on whether each word was one that
they would commonly use with their respective patients. Finally, 50 words were selected at
random for use in the interviews; in these interviews, patients were presented with each term
along with a contextual sentence and subsequently asked to define the word. Special efforts
were made by the researchers to select participants of diverse backgrounds, particularly in
terms of demographic and education attributes. In terms of results, the top five correctly-
identified medical terms consisted of ‘orally’, ’obese’, ’amputate’, ’hereditary’ and ‘vision’.
Most wrong or inadequately vague responses involved the terms ‘triglyceride’, ‘edema’ and
‘cyst’. As to education as a dependent variable, findings indicated that differences in
educational level (high school diploma versus any level of college diploma) played a
significant role in understanding among the participants. In addition, participants aged 45-64
were much more knowledgeable than participants 65 and over (Thompson & Pledger, 1993).
Both of these findings are in line with the findings of earlier studies.
In their conclusion, Thompson and Pledger (1993) remark that over the last 40 years,
a number of studies have been conducted with respect to patients’ understanding of medical
terms, and throughout these studies, that the knowledge level seems not to be increasing.
Study limitations identified by Thompson and Pledger (1993) include inability for
participants to use questions to gain knowledge with respect to terms that they were unaware,
which they would have the opportunity to (at least) attempt in a typical doctor visit. Another
noted limitation is the study’s inability to account for body language and other unspoken
exchanges; the study notes that typically, such body language can increase comprehension.
 35

Another study in understanding of common health terms was undertaken by Hadlow

and Pitts (1991). In terms of methodology, several distinctions can be made from the study
done by Thompson and Pledger (1993). In this case, a survey/questionnaire of 12 multiple
choice questions was used instead of an interview format and participants included patients,
doctors and clinical support staff; in addition, psychological terms comprised the majority of
the vocabulary assessed, as opposed to a random and general set of medical terminology. A
key aspect of this study and an important difference from Thompson’s and Pledger’s (1993)
work is the fact that there were no ‘wrong answers’. Rather, the multiple choice survey
questions contained different definitions for each term, pulled from different sources
including clinical literature and the Oxford dictionary. Instead of evaluating understanding of
each term on an ‘adequate/inadequate’ basis as Thompson and Pledger (1993) did, the
primary objective of this study was to assess differences between the manner in which
specific groups of participants define and understand a common set of terms (Hadlow &
Pitts, 1991).
Other goals of the study included determining how, if at all, understandings had
changed since previous studies, as well as to identify and explore differences in how other
(non-physician) health care workers understand and define the terminology. In terms of
results, key differences were observed in understanding between the words ‘depression’ and
‘migraine’, while all three groups (doctors, patients and other health workers) had common
understanding of ‘palpitation’ and ‘coronary thrombosis’. Other terms exhibited varying
combinations of difference between two of the three groups represented in the study. Results
of this study indicated a prominent disconnect in understanding with most of the survey’s
terms among patients, health care workers and doctors. In addition, Hadlow and Pitts (1991)
suggest that non-physician health care workers may help patients with issues of translation,
based upon analysis of how this group’s responses compared to those of the patient and
doctor groups.
Additional studies examining understanding of medical terminology include work by
McKinlay (1975), in which 87 families in Scotland were interviewed on four occasions over
a period of 18 months. The participants were split into two groups, labeled as ‘utilizers’ and
‘underutilizers’. McKinlay (1975) attended rounds with physicians and observed, noting the
most common terms used by doctors in communicating with patients. A narrowed list from
 36

this set of terms was used as the study instrument. Analysis of the findings suggested that
understanding increased with experience (i.e. with increased utilization), although in
statistical terms, the difference was not substantial enough to be deemed reliable; McKinlay
(1975) suggests that further study would be required, using a larger population, to make a
reasonable evaluation. In addition, McKinlay (1975) noted that the misunderstanding of
terms significantly exceeded physicians’ expectations. In his discussion of the findings,
earlier work by Skipper, Tagliacozzo and Mauksch (1964) is cited in considering barriers to
effective patient-doctor communication. He notes that such barriers suggested by Skipper et
al. (1964) include a desire to protect patients from too much information in the presence of
bad news, health care professionals protecting themselves from potentially unmanageable
reactions by patients and from potential discovery of errors on the part of the physician
(McKinlay, 1975).
A study of 117 patients having hypertension was undertaken, collecting responses
from participants through an interview process in order to develop a model representation of
patients’ views and understandings of their hypertension as a ‘cognitive domain’. Findings
were presented indicating that the majority of these patients were under the mistaken
impression that they had Hyper-Tension (essentially, a stress-induced condition) when in
actuality, all of the patients had been previously diagnosed with clinical hypertension (high
blood pressure). In his analysis surrounding the subject of how differences in understanding
can affect the nature of the doctor-patient relationship, and ultimately outcomes, Blumhagen
(1980, p. 224) remarks:
Plain folk say 'Hyper-Tension'; the experts say hypertension, and each thinks the
other is taking about the same thing. Perhaps it is this muddying of the waters
which allows both to function without cognitive dissonance becoming so great as
to cut off interaction. The physician doesn't have to deal with the social stresses
that don't fit his model, and the layman can reshape the physiological explanation
of biomedicine to a more amenable form. Because of the distance that is effected
by two disparate definitions, the therapeutic alliance is not threatened. But there
are occasions when dissonance caused by different models of illness does impede
healing. At those times, a full understanding of the illness belief systems which
are available to the layman and to the physician, if coupled with a willingness to
negotiate a more functional set of explanatory models, may pave the way to a
richer, deeper, and above all more satisfying experience to healing.
Boyle (1970) found, through a questionnaire-based study of 234 participants, which
was intended to examine interpretations of common medical terms and knowledge of key
 37

concepts in anatomy, that patient participants failed to agree (in terms of interpretation), on
all terms except one. His research motivation was essentially to assess readiness for clinical
computer systems in the framework of medical vocabulary, as he noted that for computer-
based diagnostic systems to be successful, “it is mandatory to have either a vocabulary of
totally unambiguous medical terms or a knowledge of the syntactic, semantic, or pragmatic
limitations of our existing medical terminology.” (Boyle, 1970, p. 289) In addition, he
remarks on the need to consider educational level differences as they relate to understanding
of terminology.
Coope and Metcalf (1979) found that social class played a significant part in
determining the patient’s level of knowledge of medical concepts. Self-identified weaknesses
in this study included the fact that the sample may not have been representative of the general
population, due to the fact that surveys were distributed exclusively in a waiting room.
Secondly, the researchers did not make note or counts of patients who refused to participate.
Thirdly, the sample was likely biased towards younger and more wiling-to-participate
patients.
Applying the findings within the literature to the problem at hand, it should be clear
to the intuitive reader that the complex terminology pervasive in health and medicine
presents an enormous obstacle to the average patient’s ability to effectively participate in any
collaboration surrounding fraudulent activities. Regardless of any level of desire that a
consumer might have to become an active participant, whether stemming from a feeling of
social responsibility or even arising from a scenario in which the consumer herself has been a
direct victim, the inability to effectively communicate with other parties prevents any transfer
of knowledge (or attempt at knowledge transfer, for that matter) from occurring in the first
place. A later chapter in the thesis will propose one potential approach to deconstructing this
barrier, leveraging findings from, and building upon through this paper’s own extension, the
literature on controlled vocabularies and ontology.

Patient Concerns Related to Data Privacy and

Security
Effective contribution by patients in health care anti-fraud efforts would, in the
majority of cases, require the sharing of personal health information. Since many frauds
involve billing for services not rendered or the exaggeration of performance, the value of
 38

patient knowledge in a collaborative environment of fruitful exchange will often lie within
the knowledge surrounding the details of his or her visit with the provider. Privacy concerns
on the part of patients are a significant issue in the industry and a known barrier to
information exchange for many consumers. The paper now examines these concerns.
Considerable literature exists on the subject of patient data privacy interests, from the
perspective of both patients as well as other parties to healthcare transactions. Implications
for patients of records disclosure are potentially significant; such consumers may find
themselves exposed to general discrimination or that of potential insurers, loss of
employment and ostracization within their respective communities. Patient records typically
include, but are not necessarily limited to, demographics, financial information,
dependencies, sexual orientation and genetic data indicating predispositions to potentially-
serious diseases. Despite the justifiable concerns of patients with respect to the potential risks
associated with undesired distribution of patient health information, there are also substantial
public and commercial interests involved; the current health care environment is one of
competing interests surrounding patient data and there are convincing points on all sides of
the debate.
Ethical justifications surrounding the protection of patient health information are
based upon these considerations with respect to individual rights (Gostin, 1997). However, as
Gostin (1997) states, there are, in fact, compelling reasons for collecting and utilizing patient
data from the perspective of societal benefit; such data is considered necessary for the
success of consumer-oriented health care, improved outcomes and, additionally, to increase
understanding surrounding the dynamics of fraud and abuse issues as they affect the industry.
Rybowski (1998) discusses at length the competing interests among players within the health
care industry, including patients; Rybowski (1998) notes that with respect to privacy
expectations and data sharing, attitudes are beginning to evolve as a result of the increasing
acceptance of the view that societal benefits must be weighed against personal privacy.
Gostin (1997) envisions a future infrastructure where electronic records will allow fraud to
be more easily detected through increased ability to analyze patterns, as well as reductions in
health care by reducing paper-based processes.
As collection, storage and maintenance of patient records have moved closer to a
fully-electronic medium, new concerns have surfaced surrounding computerization and its
 39

impacts on the privacy and security of health data. The General Accounting Office (1990)
calls attention to the fact that additional data being stored, in combination with the distributed
nature of computer networks, reduces the ability of patients to control distribution and
access. Within a distributed EMR (electronic medical record) system, potential for privacy
loss is increased, relative to standalone EMR systems or paper record systems. However,
when reasonably sufficient safeguards are employed, computerized records might be more
secure than paper-based systems. Carter (2000) points to the dangers of large databases and
citing a significant incident wherein the University of Michigan Medical Center exposed
thousands of patient records on a public web site for approximately two months. Carter
(2000) argues that views of technology as a simple solution to problems surrounding
inappropriate use of information are naïve; results from a survey conducted in the United
Kingdom indicated that over 45% of health organizations had experienced security incidents
within the last three years.
On the contrary, the National Research Council (1990) actually views
computerization as an opportunity to improve personal privacy, highlighting the ability to
implement what are, essentially, more thorough security measures than what would be
available for use in the protection of paper-based files. Such measures include role or level-
based security, data access controls and audits of electronic records access. In regards to the
significant challenges that arise with respect to patient data control in a distributed KM
environment such as a distributed electronic health records (EHR) system, Bose (2002)
recommends that patient data treatment be considered within future research; in particular, he
cites the need for additional work in the areas of system access security and data disclosure
mechanics.
It is important to note that while patients are not able to control dissemination under
all scenarios (certain exchanges are expressly permitted under the HIPAA Privacy Rule),
patients are provided complete freedom to expressly agree to provide, or to implicitly
provide, information about their health care transactions, experiences, concerns and overall
health. Several large and very active online communities currently exist
(PatientsLikeMe.com and DailyStrength.com are two such examples) where consumers are
sharing information about treatments, prescription drugs, management of chronic conditions
and more. Examining sharing in the more specific context of exchanging personal health
 40

information with other internet users, Pew Internet and American Life Project suggests that
20% of patients go to social networks where they can communicate and exchange
information with other patients, as well as experts (Shapiro, 2009). Frost and Massagli (2008)
analyzed information sharing within a specific disease group on the social networking site
PatientsLikeMe. Findings indicated that over the period of December 2006 to February 2008,
63% of patients within the group contributed at least one original comment. Further, typical
exchanges between members generally involved (a) targeted questions to other members
having relevant experience, (b) advice, and (c) creating and building upon relationships with
others based on similarities. Frost and Massagli (2008) found, in addition, that many
exchanges led to further discussion among the user base.
While most exchange of data between non-patient parties falls under the purview of
regulatory controls, patient-to-patient and patient-to-other exchanges do not. Patient
willingness to participate in any sharing and collaboration can be represented by the sum of
comfort with such sharing and a desire to contribute. Reservations surrounding data sharing
may change over the next several years; due to the inclusion within recent health care reform
legislation of prohibitions on exclusions of coverage for pre-existing conditions, it is quite
possible that a reduction in patient fear of sharing may be observed. One objective of the
questionnaire instrument used by the present study is to gauge whether changes in attitudes
surrounding sharing of personal health information should be expected.

Failure to Identify and Include a Relevant

Stakeholder
As discussed in a previous chapter, private sector efforts at combating the problem of
health care fraud through the implementation and use of collaborative systems for knowledge
exchange have thus far excluded the patient as a stakeholder and participant. In this section,
the paper discusses the literature surrounding appropriate identification of knowledge
sources, within the context of KM system design.
The knowledge management discipline places considerable importance upon
identification and utilization of all potentially-useful sources of knowledge, both internal and
external to an organization. Recognition of all available repositories of data, information and
knowledge is considered a critical success factor in maximizing the effectiveness of
knowledge generation processes. In a discussion of what Davenport and Prusak (1998) label
 41

as ‘fusion’, they introduce the ideology of, and make the argument for, bringing together
parties of diverse backgrounds, perspectives and philosophies for effective collaboration in
problem-solving activities. Cited is Nonaka (1991), whom earlier developed and presented
the concept of ‘creative chaos’, of which one component is the value inherent in having the
ability to leverage ideas from a larger and more complex collection. According to Leonard-
Barton (1995), making a conscious, deliberate effort to include a variety of players helps to
prevent reliance upon problem solutions that are familiar and convenient. Nonaka’s (1991)
concept of creative chaos is applied to workplace diversity in an organizational context by
Davenport and Prusak (1998), who argue that heterogeneity of skills and experience leads to
greater success.
For organizations, the first step in KM system planning should be to assess what
knowledge is desired or needed. This identification is crucial to structure and design of the
system (Morrissey, 2005). In terms of access, the system should be as open and inclusive as
possible, spanning boundaries. Depending on the sponsor and nature of the system, such
boundaries might include departments within an organization, geographical diversity or a
diverse group of individuals of varying backgrounds, experience levels and sub-interests in
the domain. In strong support of an open system, Wasko and Faraj (2000) suggest that the
exchange of knowledge through an open community lessens the likelihood of an entity
possessing knowledge but being excluded from participation in the knowledge exchange, and
further, that doing so distributes the obligation for community maintenance to all interested
entities.
Davenport and Prusak (1998) caution the reader, however, that in order to achieve the
potential benefits of fusion, a mental connection between participants must be established; in
order to accomplish this, “members must develop enough of a common language to
understand one another” (p. 61). This relates to this paper’s earlier discussion surrounding
common understanding and shared vocabulary and serves to further make the case that
terminological differences inherent to collaborations between diverse parties must be
reconciled in a careful, thoughtful manner.
Considering knowledge sources in a health care-specific context, Zhu (1997)
proposes the idea of knowledge as social constructs consisting of four stakeholder groups;
these include consumers, providers, agencies and sponsors. Patients are consumers, and
 42

providers include both doctors and other health care workers; agencies represent government
entities and administrative organizations possessing authority to include regulatory activities;
sponsors are essentially the taxpaying, general public (to whom government and regulatory
entities are ultimately accountable). Zhu (1997) argues that stakeholders need to exchange
knowledge in various ways and through a variety of means; further, healthcare knowledge
that is “detached from moments of truth…ceases to be effective, useful, or even meaningful”
(Zhu, 1997, p. 116). In terms of a patient encounter with his or her provider, a visit itself and
the circumstances surrounding the interaction constitute a moment of truth; such opportunity
to capture this knowledge in its actual context cannot be capitalized upon without tapping
patient knowledge as an input source. This thesis argues that major mistakes have been made
by failing to identify and leverage this valuable source of knowledge.

Lack of Awareness or Interest of the Problem Domain

A review of the literature strongly suggests that consumers have been aware of, and
discontent about, efforts to reduce the problem of health care fraud for some time. According
to Sparrow (2000), consumers are informed with regard to the issue, through a combination
of their own experiences and stories reported by the media. He states “The American public
remains angry with the industry for its greed and with the government for its historic inability
to eliminate the problem.” (Sparrow, 2000, p. xvii)
Sparrow (2000) discusses a 1998 study conducted by the American Association of
Retired Persons (AARP), wherein 2000 consumers were surveyed in an attempt to gauge
awareness of, and interest in, the problem of health care fraud. The results of this study
indicated that 83% of consumers believe that fraud is widespread within the health care
industry. Further, in terms of the rising costs of health care, more respondents pointed to
health care fraud as the primary cause than to any other factor. According to the AARP
report, the general public believes that fraud is rampant, and further believes that insufficient
actions are being taken to curb the problem.
As previously discussed, the federal False Claims Act includes provisions for private
parties to bring qui tam actions against suspected perpetrators of fraud. Research indicates
that the number of these suits have increased dramatically over a period of years, suggesting
that consumers have grown steadily more aware of and angry about the problem, as well as
 43

the government’s ability to effectively combat it. According to data collected and analyzed
by Hyman (2001), shown in Table 1, one will observe a significant trend in qui tam actions;
over a five-year period beginning in 1993 and ending in 1998, the number of health care-
related qui tam cases rose from 39 to 287, representing a nearly 636% increase. In addition,
the percentage of health care qui tam cases, as a percentage of total qui tam cases, rose from
30 percent to 61 percent over the same period. From this data, it is abundantly clear that, at
least in terms of the 1993 to 1998 period, interest in and willingness on the part of the
consumer population to take action against the problem of health care fraud grew
considerably.

Table 1. Qui Tam Cases in Health Care as a Percentage of Total Qui Tam Cases, 1993
to 1998
1993 1994 1995 1996 1997 1998
Health care qui tam cases 39 80 95 203 288 287
Health care qui tam cases / total qui tam cases (%) 30 36 34 56 54 61
Source: Hyman, D. (2001). Health care fraud and abuse: Market change, social norms,
and the trust reposed in the workmen. The Journal of Legal Studies, 30(2), 531-567.

A thorough examination of the available literature suggests that the December 1998
AARP study discussed by Sparrow (2000) represents the most recent survey of consumers
with respect to awareness of, and interest in, health care fraud. In consideration of the fact
that this study was conducted nearly12 years prior to the time of the current investigation,
this paper argues that reassessment is warranted at this time. Several questions in the
questionnaire instrument used by the present study are included for the expressed purpose of
examining the extent to which the aforementioned level of awareness and interest has
changed, if at all.

Inadequate Level of Technical Sophistication

As should be obvious, the ability of an individual or group to effectively participate in
any online/network-based collaborative environment is predicated upon the understanding of,
and capacity to use, personal computers and the internet. Effectiveness of participation is
enhanced even further by having some degree of familiarity and experience with the use of
social networks.
 44

Issues surrounding adoption and technical abilities of the over-65 age group are of
particular concern to this thesis. Because it is believed that most of health care fraud occurs
within the Medicare system, which serves the older population, challenges specific to the
elderly population may hamper participation, and thus capture of knowledge, from this
demographic. This necessitates further study, and as such, the present study’s questionnaire
assesses the level of ability and comfort with technology by responders, and additionally,
includes a question of the responder’s age.

MOTIVATING FACTORS FOR PARTICIPATION

With barriers to participation having been discussed, the paper now examines the
literature with respect to key factors in motivating individuals to become involved in
knowledge exchange systems.
Noting user participation as a critical success factor of a knowledge management
system, Ardichvili, Page and Wentling (2003) undertook a study to ascertain the motivations
behind members’ active participation in communities (as well as to identify barriers). At the
time of their investigation, factors contributing to participation were not well-understood.
The study was based upon four research questions; these questions focused on willingness to
share, barriers to sharing, willingness to use communities as a knowledge source, and barriers
to using communities as a knowledge source. To gain a better understanding, Ardichvili et al.
(2003) studied virtual communities at Caterpillar Inc. It was found that most of the
organization’s communities were formed through employee initiative, rather than as a result
of management dictates. Three specific communities were examined in this study; one was
large in terms of membership and experienced high usage rates, while the other two were
much smaller in membership and usage. A semi-structured interview process was used to
collect information for analysis.
In the Ardichvili et al. (2003) study, findings related to reasons for willingness to
contribute suggested that most employees considered their own knowledge to be a public
good; employees felt that they had an ethical obligation to the organization as a whole, as
well as their co-workers, to share their insights. Some study participants also engaged in their
respective communities as part of a desire to mentor, or to establish themselves as experts.
 45

In more general terms and outside of organizational frameworks, Wasko and Faraj
(2000) suggest that much of individuals’ participation can be attributed to a sense of moral
obligation which results in pro-social and altruistic behaviors. Further, many people feel that
the world as a whole is improved through the sharing of knowledge. In addition, Wasko’s
and Faraj’s (2000) study findings suggest that individuals who feel comfortable with their
level of expertise are more likely to feel comfortable in contributing. Riege (2005) suggests a
number of factors, including trust in other members of the community.

CHARACTERISTICS AND VALUE OF PATIENT

KNOWLEDGE
In this section, the paper examines the characteristics and dynamics of patient
knowledge and justifies the value of such knowledge to entities that wish to engage in more
complete strategies surrounding capture of knowledge as a key success factor towards
combating health care fraud.
A key theory of knowledge creation was developed and subsequently presented by
Nonaka (1991), based upon a number of studies surrounding knowledge creation within
innovative Japanese organizations. Based on these studies, Nonaka (1991) identified four
types of knowledge conversion; these are, respectively, socialization, externalization,
combination and internalization. In the KM literature, this is widely referred to as the SECI
model (or matrix). Socialization refers to the conversion of tacit knowledge to tacit
knowledge, externalization to the conversion from tacit to explicit knowledge, combination
as explicit to explicit, and finally, internalization as explicit to tacit. Knowledge conversion
occurs along this route, in the order described above, until the cycle has completed. At this
point, knowledge creation continues at a higher level and begins again at the socialization
stage; Nonaka (1991) described this cycle as a spiral of knowledge creation.
In The Knowledge-Creating Company, Nonaka (1991) describes the process and
implications at each stage of the knowledge conversion model. Exchanges of purely tacit
knowledge usually occur via observation or imitation. Here, Nonaka (1991) uses the example
of learning between a baker and his apprentice; the apprentice gains tacit knowledge and is
gradually able to improve by drawing upon that new knowledge. However, since the
knowledge is still in tacit form, it cannot be easily expressed to any other staff members; as a
result, the organization itself is unable to derive any real benefit from this type of conversion.
 46

In the explicit to explicit stage (combination), new knowledge is created by the synthesis of
discrete components of existing explicit knowledge. The example of a financial report is used
in this discussion. Despite the fact that new knowledge has been created, it is once again the
case that the organization essentially realizes no significant benefits. Tacit to explicit
conversion (externalization) is realized when one can effectively “articulate” his or her tacit
knowledge and communicate it to other members of the organization; colleagues can utilize
the newly-gained knowledge in their own work. Finally, internalization occurs when other
individuals are able to take new knowledge and alter their own frame of reference in order to
become more capable and innovative in their activities. At this stage, organizations can reap
considerable benefits. An illustration of the components of Nonaka’s knowledge conversion
model is shown in Figure 6.

Figure 6. Illustration of Nonaka’s SECI model.

Moving into a health care context, Winkelman and Choo (2003) discuss the role of,
and argue the value of, patient tacit knowledge in the context of patient-provider partnerships
for disease management applications. Winkelman and Choo (2003) highlight unique tacit
knowledge possessed by patients which is acquired over an extended period of time with
respect to knowledge of their symptoms, side effects to medications and general problems
surrounding health care delivery. In addition, the research cites the relationships and
 47

networks developed by patients among themselves as well as with their providers. While here
the discussion deals with chronic disease patients, this paper argues that such tacit knowledge
is possessed by all patients, based on their experiences in encounters with their physician,
learned knowledge surrounding medications, and in exchanging information with others. In
terms of service delivery, patients do have tacit knowledge that could lead to identification of
fraudulent behavior by providers.
Winkelman and Choo (2003) state, in general terms, that patients “provide a
heretofore untapped resource of knowledge that can be employed by healthcare organizations
to inform advancements in service delivery” (Winkelman & Choo, 2003, p. 356), and further
that “individuals possessing this tacit knowledge must be given a forum, tool or medium
through which it can be shared or socialized” (Winkelman & Choo, 2003, p. 353).
As discussed previously in this paper, Beckman (1999) proposes a third form of
knowledge; he refers to this as implicit knowledge. According to Beckman (1999), implicit
knowledge is fundamentally similar to tacit knowledge except that it can be accessed through
discussion and asking questions upon its being located; tacit knowledge is more effectively
transferred through observation. While the differences between tacit and implicit knowledge
as proposed by Beckman (1999) are subtle, this paper recognizes that patient knowledge
more closely resembles that of implicit knowledge. In any case, this thesis argues that the
patient’s perspective and his or her potential as a viable and valuable knowledge source are
well-represented by a combination of tacit and implicit knowledge.

RULES-BASED AND EXPERT SYSTEMS

By and large, the majority of efforts by payers towards combating the problem have
relied upon the use of rules-based decision support systems for pre and post-adjudication
analysis of electronic claims data. However, the literature suggests that such approaches may
not represent a complete or effective solution to a number of problems, for several reasons.
Rules-based systems perform well when appropriately applied, but are not a panacea for
attacking all problems. According to Huntington (1999), the successes and failures of such
systems have, above all else, related to the dynamics of the problem of which the system
attempted to solve. More specifically, Huntington (1999) suggests that expert systems are
best suited for well-understood and well-defined problems, and least well-suited for matters
 48

requiring considerable insight and intelligence. Because of the nature of health care fraud,
characterized by an environment wherein perpetrators continually develop and set in motion
new and more complex schemes in order to avoid detection, the problem is essentially one of
ever-changing, infinite solutions; in essence, the rules do not remain the same for very long.
As for rules-based systems comprising a complete solution to any problem or
problem domain, this is only possible where two conditions have been satisfied: (a) the
problem is small and well-defined such that heuristics can be applied to 100% of cases, and
(b) existence of heuristics that provide a satisfactory solution for all scenarios (Huntington,
1999). Other shortcomings include difficulties in scope of representation power and in the
necessity for frequent updating (Venkatasubramanian, Raghunathan, Kavuri, & Yin, 2002),
as well as the system not understanding its own limitations (McCarthy, 1984). While many
rules-based DSS products do perform well in validating claims data against government and
industry billing guidelines and best practices (for instance, identifying inappropriate bundling
or procedure codes inconsistent with the patient’s gender and age), these same systems also
fail to recognize many other forms or potential indicators of fraud. Because of this, payer
and other stakeholder efforts should place greater importance on capturing knowledge from
additional and external sources, such as patients.
 49

CHAPTER 3

METHODOLOGY

The paper now moves into a discussion surrounding the approach taken to the study
and the details surrounding the manner in which the study was conducted. The design of the
investigation is discussed first, followed by a brief description of the study population and
safeguards used in order to ensure compliance with applicable Institutional Review Board
and U.S. government research guidelines. Next, the paper presents a preliminary study model
and both primary and secondary hypotheses. Finally, the statistical methods, including an
overview of the underlying theory behind the statistical analysis for the benefit of those
readers who may be unfamiliar yet sufficiently interested.

DESIGN OF THE INVESTIGATION

The purpose of the present study is to identify, explore and gain increased
understanding of barriers to effective patient, or consumer, involvement in collaborative
health care anti-fraud activities. The study was undertaken mindful of the findings from the
earlier and exhaustive literature review, especially with respect to specific barriers identified
in more general, prior studies. Data collection was performed using a survey instrument (see
Appendix) consisting of questions based on a number of interesting dimensions, including:
 patient understanding of health and medical terminology, including industry code sets
 awareness of, interest in, and attitudes toward the problem of health care fraud
 interest in the problem of health care fraud
 patient profile, in terms of background/experience, age and level of comfort and
ability with respect to the use of computer and internet technologies
 willingness to share personal health information and/or experiences surrounding
encounters with care providers
The dimensions explored in the study, and listed above, are consistent with (generalized)
findings related to participatory barriers, such as inability to effectively communicate with
other parties within a particular domain (i.e. the ability to “speak the language”), lack of
 50

experience or awareness, disinterest (inability to recognize payoffs associated with

participation), and unwillingness to share personal information.
The use of a questionnaire for collection of responses is justified by approaches taken
in earlier studies, and in particular, several that have sought to assess the understanding of
medical terminology. All studies of medical terminology understanding that were located and
subsequently reviewed for the present study used questionnaire and/or interview
methodologies. This strategy is a reasonable one; further, it is argued that to make an
effective and useful comparison of how understanding of terms has increased since the most
recent prior study, it is necessary to maintain some degree of consistency.
An additional, and compelling, rationale for the selected study instrument is that
awareness, attitudes and interests cannot be systematically measured through observation or
other related techniques. In order to realistically gain insights into the knowledge and
mindset of a patient (consumer), any investigation must involve asking questions of the
population.
It is hypothesized that a significant barrier to active and effective involvement in
collaborative anti-fraud efforts by patients is a lack of understanding of health and medical
terminology, creating enormous challenges in communications and knowledge transfer. The
present study argues that patients are significantly concerned about the economic and social
implications of the problem, and further, willing to participate in collaborative knowledge-
sharing efforts yet effectively unable to do so.

POPULATION
With one exception, no special or extraordinary efforts were made to specifically
include or exclude any individual or demographic group from participation in the survey. On
the contrary, the ideal data set for a study of this nature should consist of as wide and varied a
cross-section of the consumer base as is practical. The previously-noted exception was that of
excluding persons under the age of eighteen (18). The taking of this measure was, and is still,
believed to be immaterial to the study findings; however, this exception is noted here for the
sake of completeness. The sole reason for this decision was to simplify matters of
compliance with Institutional Review Board research conduct requirements.
 51

The survey was distributed in two ways: electronically (via the internet), and in-
person (at varied locations upon both public and private property where permission to engage
in distribution activities was granted). Exactly 100 questionnaires were returned or
submitted.

PROTECTION OF HUMAN SUBJECTS

Several steps were taken in order to protect study participants from any possible
harm, regardless of how remote. Firstly, all responses were carefully collected in both a
confidential and an anonymous manner. For the electronic component of the distribution
process, an online survey management and collection site, SurveyMonkey.com, was used.
Even by default, this site collects very little information that could be used to identify a
particular respondent (the only such information collected is that of the respondent’s IP
address). This behavior is configurable by the survey creator, and the aforementioned
configuration was performed. For physical distribution where face-to-face contact was
unavoidable, steps were taken to ensure that distribution and collection activities only
occurred outside of a 15-mile radius from the researcher’s place of residence; this precaution
was taken in order to dramatically reduce the likelihood of encountering any person known to
the researcher during the survey distribution process. A contingency plan was established
prior to beginning the distribution, wherein if the researcher did encounter any person known
to him, that a survey response would not be accepted from the known individual. Fortunately,
this contingency plan never needed to be enacted. In both the physical and electronic
distribution processes, personally-identifying information of any type was neither requested
nor accepted from participants.

TREATMENT OF DATA
The web site used for collection of responses to the electronic version of the survey
automatically tabulates and makes ready all data for download as a Microsoft Excel
worksheet. Physically-collected responses were manually entered into the downloaded Excel
worksheet as additional responses. Averages and standard deviation calculations were done
within Excel, using the available built-in formulas for such purposes. The majority of survey
questions used a 7-point Likert scale (ranging from Strongly Disagree to Strongly Agree); for
 52

purposes of making the performing of calculations more straightforward, these responses

were converted to the equivalent number, ranging from 1-7.
It should be noted here that surveys having one or more Likert-style questions
unanswered, the mean response was used as the response to such questions, for calculation
purposes. This is an acceptable method of handling such a scenario, validated by a countless
number of other studies.

DATA ANALYSIS PROCEDURES

Further calculations and analysis beyond those described above were
conducted using the IBM SPSS software (version 18). The software used is well-known and
commonly used for both academic and commercial research purposes of varying complexity.
Data was imported from Excel worksheets into the SPSS product, where an ANOVA
(analysis of variance) test was run first, followed by an OLS (ordinary least squares) linear
regression analysis, for each of this study’s model hypotheses. Performing ANOVA tests
prior to running any regression is common practice, and necessary; these tests essentially
validate whether or not a regression is worth running, or whether the correlation between
variables is likely to be purely related to chance. The following section describes the model
and hypotheses.

AN IN-DEPTH LOOK AT THE MODEL

In an earlier chapter, expected relationships within the present investigation were
introduced. At this time, the rationale behind these relationship assumptions is discussed.
Background (or demographics) is expected to affect level of awareness of the problem
domain. As the problem has grown, investigations and actions related to health care fraud
have appeared more frequently in both online and print news media. It is assumed that
reading of the news is more common for certain age groups and backgrounds as opposed to
others, and further, that more exposure to news in general increases the likelihood of
exposure to health care fraud-related content, thus increasing awareness of the problem
domain. Level of technical understanding is also believed to relate to awareness. It is also
hypothesized that both background/demographics and technical understanding are tied to
understanding of health and medical terminology. Naturally, one would expect persons with
a background in the medical field (whether due to working as a clinician, employee of a
 53

health insurance plan or some other health care occupation) to be more familiar with medical
terminology. In addition, since much of medical terminology involves complex code sets
(e.g. CPT, ICD-9, ICD-10, HCPCS, to list only a few) it is believed that a more technically-
oriented person would find it somewhat easier to understand how these coding systems work
in practice.
This thesis hypothesizes that patient participation in anti-fraud activities (whether
measuring willingness, ability or propensity) is most likely with a reasonable understanding
of medical terminology, at least (some) awareness of the problem domain, a willingness and
interest in sharing personal health information (for the purpose of facilitating research), and
finally, a sense of active interest and involvement in one’s own personal health. Medical
terminological understanding is considered necessary because effective exchange of
knowledge in this problem domain is greatly facilitated by having some degree of common
ground, shared understanding and context. Additionally, findings in this paper’s literature
review strongly suggest that a person’s willingness to collaborate, share and exchange
information is greatly increased when he or she feels a sense of confidence in his or her own
knowledge and experience. The expectation of finding awareness to be a significant factor is
based on the belief that, if a person is unaware of the existence or magnitude of the problem,
the person is unlikely to be aware of anti-fraud efforts and/or to be sufficiently moved to take
the initiative to become involved in any such efforts.
Since meaningful exchange of knowledge in an anti-fraud collaborative environment
would certainly require sharing of clinical experiences with a patient’s doctors, willingness
and comfort in sharing is considered. In addition, recent legislation included in 2010 health
care reform law may affect people’s perceptions and degree of comfort in sharing personal
health information; this is explored in the study.
Based upon the above, a functional model is now introduced for analysis purposes.
This functional model is a direct representation of Figure 1.
The thesis presents the following model of factors influencing feasibility (represented
as “willingness”, as a purely practical matter) of patient participation in collaborative anti-
fraud systems and activities:

Pw ≡ ƒ(Pa, Ut, Ud, A, S, I)

 54

Where:

Pw ≡ Willingness to Participate
Pa ≡ Actual Prior Participation
Ut ≡ Understanding of Health and Medical Terminology
Ud ≡ Understanding of Documents and Provider Instructions
A ≡ Awareness of Problem Domain
S ≡ Willingness to Share
I ≡ Involvement and Interest in Personal Health

The major hypothesis, based upon the model, as follows:

H1: Pw ≡ f(Ut)
H2: Pw ≡ f(A)
H3: Pw ≡ f(S)
H4: Pw ≡ f(I)
H5: Ut ≡ f(D,T)
H6: A ≡ f(D,T)

Where, introducing new variables:

S ≡ Willingness to Share
D ≡ Demographics and Background
T ≡ Technical Abilities
In summary, the model suggests that patient willingness/ability to participate in anti-fraud
collaboration systems and other group efforts is essentially a function of technical abilities,
background, awareness/interest, willingness to share personal health information, and the
degree to which the individual understands health/medical terminology.
As previously discussed, ordinary least squares regression techniques were utilized
for this study to test the above-described hypotheses. First, an ANOVA test, and then a
regression, was run using the OLS (ordinary least squares) linear method for the overall
 55

model, with willingness to participate as the dependent variable, and all variables from the
overall model included as explanatory variables. With no a priori hypotheses having been
made with respect to determining the order of entry of the predictor variables, a direct
method was used for the multiple linear regression analyses. Subsequently, regressions were
run for secondary hypotheses in a similar manner to that described above.
 56

CHAPTER 4

RESULTS AND DISCUSSION

This chapter presents the findings arising from analysis of data collected via the
aforementioned survey instrument.

PRESENTATION OF THE FINDINGS

Unless otherwise noted, survey questions discussed in this section employ a 7-point
Likert scale.

Understanding of Terminology, Provider Instructions

and Common Documents
In terms of participants’ comprehension of Explanation of Benefits (EOB) forms,
60% indicated that these documents were difficult to understand. The average of all
responses to this question was 3.22, with a standard deviation of 1.69. When asked to
identify reason(s) for difficulties in interpretation of these documents, 57% of respondents
indicated a lack of understanding of health and medical terminology. Participants were also
asked about their understanding of billing statements received from their primary care
physician and other providers with whom they have had contact; 34% indicated some level of
disagreement when asked if these documents were easy to understand. In this case, an
average response of 4.24 and a standard deviation of 1.64 were observed. See Table 2.

Table 2. Understanding of Common Documents

Topic Average Response Standard Deviation
Understanding EOBs 3.22 1.69
Understanding Billing Statements 4.24 1.64

In the survey’s matching section, wherein respondents were asked to match twelve
(12) health and medical terms to their respective definitions and/or industry-standard codes,
or vice versa. The two-highest incidences of correct responses were to the terms
“inflammation” and “treatment”, with correct response rates of 72 and 57%, respectively.
 57

The two least-correctly identified terms or codes were “99213” and “460”, with only 2 and
5% answering correctly, respectively. Respondents’ overall scores for the matching section,
in terms of percentage correct, ranged from 0 to 66.67, with an average score of 30.42% and
standard deviation of 17.5. In terms of understanding of instructions and/or explanations
received from participants’ providers, 82% felt that they did. The average response was 5.24
with a standard deviation of 1.34. See Table 3.

Table 3. Understanding of Terminology, Provider Instructions, Common Documents

Topic Average Response Standard Deviation
Terminology Comprehension 30.42 (%) 17.5 (%)
Understanding Doctor 5.24 1.34
Instructions

Awareness of the Problem Domain

To assess participants’ general awareness of the problem domain, two survey
questions were used. The first of these questions assessed the respondents’ understanding of
the social and economic magnitude of the problem, whereas the second served to essentially
“quiz” respondents’ on which party to the U.S. health care system most often engages in
fraudulent behavior. For the latter question, “doctors” is the most correct response, as the
literature clearly reveals that providers have been identified as the leading perpetrators of
health care fraud, where such perpetrators employ a variety of billing practices ranging from
unethical to illegal. In terms of comprehension of the problem magnitude, 78% of
respondents agreed, ranging from somewhat to strongly, that health care fraud represents a
large problem for the U.S. health care system. For this set of responses, the average response
was 5.66 with a standard deviation of 1.29. However, only 12 respondents knew that
providers are the most common perpetrators of health care fraud. See Table 4.

Table 4. Awareness of Problem Domain

Topic Average Response Standard Deviation
Recognition of problem 5.66 1.29
magnitude
 58

Attitudes toward the Problem

13% have had some sort of anti-fraud related experience. 68% desire to be involved
with an average response of 5.08 and standard deviation of 1.48. 86% indicated that they
would be bothered if they had knowledge of fraud being committed by their doctor, with an
average response of 6.03 and standard deviation of 1.63. 81% said they would report
suspected fraud (at least somewhat agreed) with average response 5.55 with standard
deviation of 1.57. See Table 5.

Table 5. Attitudes Toward the Problem of Health Care Fraud

Topic Average Response Standard Deviation
Desire involvement in anti-fraud 5.08 1.48
efforts, activities
Would be bothered if their 6.03 1.63
provider was committing fraud
Would report suspected fraud 5.55 1.57

Sharing (Actual and Willingness)

48% of respondents have shared or otherwise exchanged health information on a
social-networking site. Average response was 4.05 (neutral/neither agree nor disagree) with
standard deviation of 1.87. When asked whether they would feel more comfortable sharing or
exchanging personal health information in light of health care reform prohibitions against
exclusions via pre-existing conditions, 51% at least somewhat agreed that they would feel
more comfortable. 12% strongly agreed. In terms of average, it was 4.67 and the standard
deviation was 1.66. See Table 6.

Table 6. Sharing of Personal Health Information

Topic Average Response Standard Deviation
Have already shared (personal 4.05 1.87
health data)
Would feel more comfortable 4.67 1.66
sharing health information with
preexisting condition exclusions
(under health care reform law)
 59

Demographics and Background

With respect to age of survey respondents, the majority (67%) identified themselves
as being between the ages of 26 and 35. No respondents identified themselves as being over
the age of 65. Two respondents elected not to answer this question. The second and third-
most common age ranges were 18 to 25, and 36-45, respectively. In terms of level of
education, 46% possess a graduate degree, with 32% currently working towards such a
degree. Four respondents identified themselves as possessing doctoral degrees. Three
participants elected not to answer this question. Only 6% of respondents identified
themselves as Medicare beneficiaries, with 93% possessing other (or no) insurance and 1%
providing no answer to the question. In terms of professional experience within, or somehow
related to, the health care industry, 20% answered the question affirmatively.

Technical Abilities
94% indicated they were comfortable using a computer. The average response was
6.73, with standard deviation of 0.83. 95% indicated that they felt comfortable with internet,
with average response of 6.71 and standard deviation of 0.79. See Table 7.

Table 7. Technical Abilities (Respondent Self-Assessment)

Topic Average Response Standard Deviation
Comfortable using a computer 6.73 0.83
Comfortable using the internet 6.71 0.79

As a reminder to the reader, the major model is as follows:

Pw = f(Pa,Ut,Ud,A,S,I)

Where:

Pw = Willingness to Participate
Pa = Actual Prior Participation
Ut = Understanding of Health and Medical Terminology
Ud = Understanding of Documents and Provider Instructions
 60

A = Awareness of Problem Domain

S = Willingness to Share
I = Involvement and Interest in Personal Health

The individual hypotheses were listed in the previous chapter as follows:

H1: Pw = f(Ut)
H2: Pw = f(A)
H3: Pw = f(S)
H4: Pw = f(I)
H5: Ut = f(D,T)
H6: A = f(D,T)

Where, introducing new variables:

S = Willingness to Share
D = Demographics and Background
T = Technical Abilities

First, a regression was run using the OLS (ordinary least squares) linear method for
the overall model, with willingness to participate as the dependent variable, and all variables
from the overall model included as explanatory variables. With no a priori hypotheses having
been made with respect to determining the order of entry of the predictor variables, a direct
method was used for the multiple linear regression analyses. In terms of specific results, the
independent variables produced an R2 of 0.334 (F = 7.772, df=6, p =0.000), with the
standard error of the estimate calculated to be 1.178, as shown in Table 8. The results of the
regression indicate a moderate level of intercorrelation between the variables (R=0.578).

Table 8. Model Summary for Regression of Willingness to Participate on Major

Independent Variables
R R Square Adjusted R Square Std. Error of the Estimate
0.578 0.334 0.291 1.178
 61

Next, an ANOVA (analysis of variance) test was run; ANOVA results were
favorable, as shown in Table 9, and indicate that all variance is explained by the aggregate
model. Based on these results, continuation of the analysis is warranted.

Table 9. ANOVA Results for Overall Regression

Sum of Squares df Mean Square F Sig.
Regression 64.717 6 10.786 7.772 0
Residual 129.073 93 1.388
Total 193.79 99

In terms of the model coefficients, awareness (p=0.000), prior participation in health

care anti-fraud activities in any manner (p=0.012), and involvement/interest in personal
health (p=0.003) are the only significant coefficients. Understanding of terminology,
understanding of documents and previous sharing experience indicated p-values of 0.699,
0.893 and 0.593, respectively. These results are illustrated in Table 10. Moreover, the
coefficient representing previous experience in sharing and/or exchanging health information
via a social network has a negative beta value, which would indicate that the relationship
between willingness to participate and such previous sharing experience is negative.

Table 10. Regression Coefficients for the Overall Model Regression

Unstandardized Standardized
Coefficients Coefficients t Sig.
B Std. Error Beta
(Constant) 1.462 0.767 1.907 0.060
GEN_UNDERSTANDING 0.014 0.103 0.012 0.135 0.893
PREV_SHARING_EXP -0.035 0.066 -0.047 -0.537 0.593
AWARENESS 0.351 0.096 0.328 3.658 0.000
TERMINOLOGY_SCORE 0.003 0.007 0.035 0.388 0.699
INV_IN_PERS_HEALTH 0.28 0.093 0.277 3.009 0.003
ACTUAL_PREV_PARTIC 0.128 0.05 0.224 2.554 0.012

The correlation between willingness to participate in antifraud activities, and prior

participation in any such activities, is expected and thus it is deemed unnecessary to propose
this relationship as a separate hypothesis. Based upon the findings described above, this
study cannot reject the null hypotheses for H1 and H3; however, the null hypotheses for H2
and H4 are rejected.
 62

Continuing with the analysis, two additional OLS regressions were run, in order to
test hypotheses H5 and H6. Once again operating in the absence of any a priori hypotheses
for order of variable entry, the regression of understanding of medical terminology on
demographics/background and technical abilities, we have an R=0.339, R2 of 0.115
(indicating somewhat low intercorrelation), p=0.020. The only significant coefficient is
technical ability (p=0.003). Therefore, this study must reject the null hypothesis. The results
of the analysis are shown in Tables 11, 12 and 13.

Table 11. Overall Result of Regression of Medical Terminology Understanding on

Background and Technical Abilities.
Adjusted R
R R Square Std. Error of the Estimate
Square
.339 0.115 0.077 16.8891655

Table 12. ANOVA Test for Regression of Medical Terminology Understanding on

Background and Technical Abilities.
Sum of
df Mean Square F Sig.
Squares
Regression 3509.467 4 877.367 3.076 .020
Residual 27098.172 95 285.244
Total 30607.639 99

Table 13. Listing of Coefficients for the Regression of Medical Terminology

Understanding on Background and Technical Abilities.
Unstandardized Standardized
Coefficients Coefficients t Sig.
B Std. Error Beta
(Constant) 14.272 7.326 1.948 .054
EDUCATION_LEVEL -1.958 1.728 -0.112 -1.133 .260
TECH_AVG 6.17 2.042 0.3 3.022 .003
IS_MCR -1.232 7.404 -0.017 -0.166 .868
AGE_RANGE 4.898 3.686 0.133 1.329 .187

For awareness regressed on demographics/background and technical abilities,

R=0.322, R2=0.104, p=0.014. As in the previous regression, the only significant coefficient
is technical ability (p=0.002). The results of this analysis are shown in Tables 14, 15 and 16.
 63

Table 14. Overall Result of Regression of Problem Awareness on Background and

Technical Abilities.
Adjusted R
R R Square Std. Error of the Estimate
Square
.322 0.104 0.076 1.258

Table 15. ANOVA Test for the Regression of Problem Domain Awareness on
Background and Technical Abilities.
Sum of
df Mean Square F Sig.
Squares
Regression 17.575 3 5.858 3.7 .014
Residual 151.985 96 1.583
Total 169.56 99

Table 16. Listing of Coefficients for Regression of Problem Domain Awareness on

Background and Technical Abilities.
Unstandardized Standardized
Coefficients Coefficients t Sig.
B Std. Error Beta
(Constant) 4.675 0.521 8.977 .000
EDUCATION_LEVEL -0.092 0.129 -0.07 -0.711 .479
AGE_RANGE -0.248 0.271 -0.09 -0.916 .362
TECH_AVG 0.466 0.148 0.304 3.139 .002

DISCUSSION OF THE FINDINGS

In terms of patient understanding of health/medical terminology and vocabulary, the
matching section of the survey instrument showed equally dismal results to the earlier
findings arising from research by Thompson and Pledger and others cited in the literature
review. One of the primary goals of this study was to determine if understanding of
terminology by patients had increased by and significant degree since the time of the most
recent comparable study, which was conducted a number of years ago. The results of the
present study were surprising to the researcher, expecting considerably more favorable
findings, given the explosion of interest in personal health over the last five years, as well as
steadily increasing internet, television and print media coverage of health and medical
matters. One would reasonably expect a certain level of fluency at the present time,
especially among younger survey respondents (who constituted the great majority of
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participants), as those in the 18-24 and 25-34 age groups consume more media than older
individuals. After much consideration and reflection on the results, it is proposed that the
design of the matching section and instructions given to participants could have been
somewhat improved. Such modifications might well produce results more closely aligned
with the original expectations.
While designing the survey instrument, another objective of particular interest was
the assessment of how patient concerns and attitudes towards sharing of personal health
information might be affected by recent health care reform legislation that would prohibit
insurers from denying coverage to individuals based upon pre-existing conditions. It has been
the researcher’s feeling, for some time now, that people’s obsession with health information
privacy and reluctance to share information were primarily tied to fears of the information
being used against them by their insurance carriers. However, data collected from the survey
shows no significant correlation. This may be due to recent happenings wherein lawsuits
have been filed, and plans discussed among members of Congress, to attempt to repeal
components of health care reform law. It is possible that respondents are aware of these
activities and consequently have less than full confidence that the legislation (and the
included, aforementioned protections) will withstand its opposition.
The study data suggests that patients feel somewhat confident in their understanding
of their doctors’ instructions. However, the data also suggests a certain level of difficulty in
understanding provider and payer documents, particularly with respect to EOB (Explanation
of Benefits) forms. Furthermore, when participants who expressed that they did have
difficulties interpreting these documents were asked to identify the reason(s) why, a
significant number of respondents pointed to lack of understanding of medical terminology
and codes. This has major implications for effective patient participation in anti-fraud
activities (such as reporting suspected fraudulent activity to insurers or to law enforcement
agencies) since the ability to interpret and understand EOB documents in the context of
patients’ encounters with health care providers is necessary in order to identify many forms
of fraudulent behavior. When considering a health care encounter, or visit, the patient and
provider are typically the only parties with full knowledge of the details of that encounter,
such as procedures performed and diagnoses given. The carries obvious implications, in that
if a provider wishes to engage in fraudulent billing practices with the patient’s insurer, the
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patient may well be the only party to the transaction that has sufficient information to
identify discrepancies between the events of the encounter and any bills or documentation
submitted by the rendering provider to his or her insurer.
Getting the patient involved in combating the problem will require education and a
means for translating complex information into language that the patient can easily
understand. In the following chapter, a proposed knowledge management system is described
that could conceivably play a role in the fight against health care fraud, by facilitating
increased patient comprehension of medical terminology and codes, resulting in increased
patient ability to participate and increased knowledge capture; such a system could lead to
better understanding of the problem domain and, thus, increased identification and more
successful enforcement of health care fraud, waste and abuse.
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CHAPTER 5

A PROPOSED KM SYSTEM MODEL

Based upon the findings of the study (leveraging both the results of the distributed
questionnaire as well as the literature review), the paper now introduces and proposes a
model knowledge management system designed to contribute towards combating the
problem of health care fraud, waste and abuse.
The development and presentation of this model is warranted due to the relative lack
of success realized by past and current anti-fraud efforts, as well as the aforementioned
findings. As a reminder to the reader, one of this study’s key conclusions is that several
significant challenges hindering the increased effectiveness of learning, knowledge transfer
and ultimately, enforcement, within the anti-fraud domain can be met by increasing patient
participation and that such participation can be encouraged through improving accessibility
of knowledge to patients while, at the same time, providing privacy controls that satisfy
consumers’ growing concerns. Further, the results of the present study’s questionnaire
strongly suggest that there is significant interest on the part of consumers in becoming more
actively involved in efforts towards reducing the staggering socio-economic costs associated
with health care fraud.
First, a brief review of current approaches used, as well as challenges faced, within
the problem domain is offered. Subsequently, the paper introduces and describes the
elements of the proposed model and distributed KMS prototype.

REVIEW OF CURRENT APPROACHES AND CHALLENGES

WITHIN THE PROBLEM DOMAIN
As has been previously discussed, efforts to combat health care fraud (and other
types, for that matter) can be considered along two dimensions: identification and
enforcement. Identification has been the primary activity of payers, including both private
carriers and government-sponsored plans such as Medicare and Medicaid. Such attempts at
identification have primarily consisted of claim data scrubbers that seek to detect anomalies
during the adjudication phase of payers’ claims processing workflows. These scrubbers are,
 67

essentially, DSS (decision support systems) predominantly utilizing pre-programmed and

occasionally updated rules based on industry best practices and government payer guidance
as they apply to appropriate coding and billing conventions. In addition, “common sense”
validation logic is included; for example, a claim indicating a diagnosis of pregnancy in such
case where the patient is actually male will trigger an alert or mark the claim as denied
(depending upon preferences set by the payer within the software/system).
At least two significant shortcomings should be immediately apparent with this
approach. Firstly, anomalies are not identified until time and point of adjudication; this is a
reactive approach versus one in which proactive steps are taken to reduce the problem.
Secondly, and as has been discussed in detail within the literature review, the health care
fraud environment is characterized by its dynamic nature, particularly in terms of the
criminal schemes and methods employed. As quickly as any given strategy has been
discovered and safeguards put in place to reduce or prevent future vulnerabilities to such an
approach by the perpetrators, several new schemes have already been conceived and
employed, at the expense of payers and the general public. As a result, it is unrealistic to
expect such systems to detect a significant percentage of fraudulent claims. Additionally,
such systems only examine claims data anomalies but many other types of health care fraud
exist with their own respective economic and social implications (particularly within the
framework of quality of care). It is argued that these systems can play an important role
within a larger and more complete anti-fraud solution, but that they are not a sufficient and
satisfactory solution independent of other efforts.
In terms of enforcement, suspected fraud against the Medicare and Medicaid
programs is investigated by a number of federal entities, including the OIG (Office of the
Inspector General) and the FBI (Federal Bureau of Investigations). Private payers may report
suspected incidents to law enforcement agencies or elect to handle the matter civilly; in
addition, such payers often use administrative and credentialing-related actions, including
sanctions, in clear cases of fraudulent claims submission. In either case, whether a public or
private payer, such administrative actions, investigation and enforcement are ultimately
triggered by the identification of unusual behaviors, most commonly from claims being
flagged by the types of DSS discussed above or through other review processes.
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While law enforcement efforts have had notable victories with respect to large sum
recoveries of fraudulently-obtained funds (several landmark cases and enforcement actions
are discussed in the literature review), such actions have, economically speaking, only
scratched the surface of recovering the extent of monies unlawfully fleeced from the public
trust. Additionally, providers who have engaged in fraudulent activities will, in many cases,
elect to close their operations and declare bankruptcy as soon as they become aware of
impeding actions, instead of defending themselves at trial and facing the possibility of
staggering civil judgments. In such cases, the fraudulently-obtained funds may never be
recovered and returned to the taxpaying public. Limitations as to the effectiveness of law
enforcement’s activities also exist; in particular, organized crime syndicates both foreign and
domestic have become increasingly involved in health care fraud due to its relatively low risk
and potentially enormous rewards. Due to the highly lucrative nature of these crimes,
organized crime groups are mostly undeterred from continuing to engage in these schemes,
despite the threat of substantial monetary actions and long terms of incarceration.
Claims analysis software and law enforcement cannot possibly represent the entirety
of an effective attack against the problem. Due to the problem magnitude and complex
characteristics, additional and more proactive solutions have become critical. In
consideration, the paper proceeds to introduce and describe, in detail, a proposed model for
the development of a distributed KM system that effectively facilitates collaboration among
all relevant stakeholders by overcoming current challenges that would have restricted the
involvement of all parties to date, and that, additionally, increases public awareness and
knowledge of the problem domain.

A NEW APPROACH
Based on an exhaustive review of the relevant literature and current anti-fraud
activities related to the health care industry, no system currently exists which has a
significant number of the components, critical success factors and objectives discussed in this
chapter. However, development of such a system is warranted; as has already been
established in this thesis, appropriate knowledge is a highly important input to anti-fraud
investigations, and, in general, to increasing understanding within the problem domain. A
 69

well-designed KM system supporting knowledge transfer with a common sense of purpose

could (realistically) have significant impacts within the domain.
Previous anti-fraud efforts have been a mishmash of poorly-organized or too-
exclusive industry groups, payer-based claims analysis software that is difficult to keep
updated with the pace of the changing environment of health care fraud, and, in addition,
collaborations between law enforcement agencies hampered by politics. A computer-based
collaborative platform that invites all stakeholders, and that supports the unique
requirements of these diverse stakeholders, is needed. Jennex and Olfman (2006) discuss
system quality as one of several KM success factors. According to Jennex and Olfman
(2006), a “computerized system that utilizes network, semantic Web, and data warehouse
technologies will result in the highest levels of system quality” (Jennex & Olfman, 2006, p.
57) due to how well IT facilitates search, storage, retrieval and visualization.

CHALLENGES IN DESIGN AND IMPLEMENTATION

A number of specific challenges exist with respect to the design and implementation
of a system such as the one described in this chapter. While any KMS design process must be
undertaken carefully, the proposed system requires particular attention. Such considerations
are discussed in this section.

Shared Understanding of Health and Medical

Terminology
Analysis of the data from the questionnaire distributed as part of this study reveals
that patient understanding of health and medical terminology has remained relatively poor,
consistent with earlier studies conducted by Thompson and Pledger, et al. In order to develop
an appropriate model and implement a successful knowledge management system which
facilitates active participation among diverse users (and diverse groups or types of users),
substantial consideration must be given to the creation of a shared vocabulary and
characterization of the complex relationships between terms; such shared terminology is of
vital importance in developing consistent mental models among system participants and
facilitating useful information and knowledge exchange. The system must meet the challenge
of making terminology accessible which is, currently, characterized by differing
understandings among different persons and groups.
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Legal Considerations
HIPAA statutes protect patients against unauthorized disclosure of personal health
information to third parties, in addition to other privacy mechanisms and safeguards. It is
important to consider that these statutes allow patients themselves to retain control over such
dissemination of data; as it stands, a patient may voluntarily consent to the sharing of his or
her medical information with any third parties, at any time and for any reason. In the context
of the system framework described within this chapter, current laws would not create any
significant barrier to free and effective information exchange.
In terms of implementation of a KM system consistent with the described model and
architecture, one should be particularly careful, however, to obtain written and/or electronic
documentation noting the consent of all patient-participants to share personal health
information. Such measures are suggested here merely for the sake of prudence and
performing due diligence.

Security and Privacy Considerations

Among other things, the proposed system relies heavily upon user-shared data, which
is subsequently converted to information and finally to useful knowledge that can be
leveraged in continued, current anti-fraud activities as well as create new opportunities for
combating fraud. Some of this data is considered personal in nature; as such, a major
challenge to the design and implementation of an effective model and system, respectively, is
obtaining meaningful information from users while still respecting and protecting privacy
based upon the comfort level of each and every user. Additionally, in cases where personal
data is in fact shared, a responsibility exists to design and implement appropriate security
controls that prevent undesired exposure of protected or personally-identifiable data.

Encouraging Patient Participation

A challenge facing any system is that of attracting the participation of the system’s
intended users and groups. In the proposed model and system implementation, the usefulness
and effectiveness of the system increases dramatically with corresponding increases in the
size of the user base. Based on the literature, participatory barriers often revolve around lack
of comfort with one’s level of expertise, lack of time, differences in experience and education
levels, and finally, lack of trust in other members of the community. To be effective in
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gaining active participation, the system must create a level playing field among its users, in
terms of accommodating varying backgrounds, degrees of knowledge and characteristics of
users’ experiences with respect to health and medicine. Finally, a system of trust must be
established among users both within and across groups. This is made more challenging due
to the distributed and purely virtual nature of the proposed KM system, wherein no face-to-
face interaction is possible.

CRITICAL SUCCESS FACTORS

For the proposed model, this paper now discusses perceived critical success factors,
some of which are particular to this system but for all of which apply to general KM systems
design.

Provide Effective Privacy Preferences and Controls

Earlier analysis showed no correlation between health care reform legislation related
to prohibition of pre-existing condition exclusions, and an increased willingness or interest in
sharing personal health data in a social or social networking context. It is predicted that
patient privacy concerns will always be a primary consideration, and one of the largest
challenges, in creating any virtual or other environment with the goal of encouraging such
sharing. As a result, complex security and privacy controls are an absolute necessity; such
controls must be highly-configurable by users and should use granular methodologies in
implementation. In terms of patients, the ability to explicitly include or exclude pieces of
one’s health record or individual medical-related events is critically important.

Get the Right Information to the Right People at the

Right Time
According to Jennex and Olfman (2006), knowledge quality is the KM success factor
responsible for ensuring that the appropriate knowledge, with the necessary contextual basis,
is usable by the appropriate user when it is needed. Jennex and Olfman (2006) explain
knowledge quality as being composed of KM strategy and process, richness of knowledge,
and quality of linkages.
Richness and linkages are of particular importance in the proposed system, where the
data associated with the system should be available to an engine which is highly accessible
 72

to, and supports sophisticated integration with, private and public payers’ claims
management systems. Payers subscribe to this service, so that at time of claim adjudication,
alerts and other flags can be raised which suggest to claims department staff members and
risk management professionals that additional review of claim(s) is warranted. Such alerts
might be the result of a particular member/patient or provider being flagged in the system as
potentially involved in questionable activities.

Include and Capture Knowledge from All Relevant

Stakeholders
In order to effectively serve its purpose, the system must invite, welcome and include
all relevant stakeholders as system users. It is critical to recognize that each user type (to be
discussed in a forthcoming section) plays a unique role in the virtual ecosystem, by bringing
with it unique knowledge of both the tacit and explicit varieties. Jennex and Olfman (2006)
discuss a KM strategy/process construct as a component of knowledge quality; this construct
relates to design of processes for appropriate identification of system users, as well as
decisions regarding what knowledge is needed (and thus should be captured for reuse). As
discussed previously in this paper, getting patients involved via patient knowledge capture is
a key concern, as this group has (thus far) been excluded from participation in the industry’s
collaboration and knowledge exchange activities surrounding the combat health care fraud.

Facilitate Communication between Parties of Diverse

Vocabulary Sets
Since users of the system will constitute diverse parties, especially in terms of
experience, knowledge and background, it is critically important that the model is designed
in such a way as to facilitate effective communication between these various user types (as
well as among individual users with a group, who will likely have their own unique
characteristics).
The proposed model defines a number of user types, including but not limited to
patients, providers, representatives of regulatory entities and insurance carriers, and academic
researchers. As has been discovered through a review of the literature, and as has been
explored in the study, persons of different backgrounds often use different terminology to
describe the same thing, and often encounter challenges in understanding others’ own
 73

terminology. The solution employed in this author’s model comes in the form of a controlled
vocabulary. Further, common terms and definitions used by different groups are linked, or
mapped, to each common object, or term. The use of a controlled vocabulary is discussed
further in a subsequent section of this chapter, in greater detail and including useful
examples.

Ease and Convenience of Use

One of the core challenges in the development, implementation and user adoption
phases of any KM system is creating an environment that is easy to use and convenient for its
users in terms of contributing knowledge. Capturing knowledge generally requires an
interruption in users’ routine work and a considerable investment of time; many potential
system users are simply unwilling to invest such effort. Jennex and Olfman (2006) discuss
user satisfaction and intent to use/perceived benefits as KM success factors; this ties in well
with this paper’s proposed system model and the ease of use objective.
As such, a successful KM system should seek to facilitate and encourage knowledge
capture from users in a minimally-invasive way that is intelligently incorporated into users’
current activities. This consideration is particularly relevant to the patient user role in the
proposed system model. People are generally busy; despite the survey findings wherein the
majority of respondents expressed willingness to participate in anti-fraud activities, it is
difficult to imagine many patients exerting significant effort to use a KMS for this or any
other purpose. An approach for streamlining capture of knowledge from patients in a mostly-
transparent way is discussed later in the chapter.

Effective Search Functionality: Locating Knowledge

This relates to the previously-discussed unique terminology and vocabularies which
exist among different system user types. In order to achieve a high degree of usability for all
groups within the system, each must have the ability to search for and locate relevant
information under the group’s own understanding of the term, definition, model or domain as
applicable. All terminology linked or mapped to a term in the controlled vocabulary is used
to return terms from the controlled vocabulary to the searching user.
The above primarily relates to facilitating users’ ability to efficiently locate, and
subsequently leverage, codified knowledge. However, as discussed by Jennex and Olfman
 74

(2006) in their work on KM success models, users who are new to a KM system often feel
inclined to use human knowledge sources from those who they perceive to be experts in the
domain; this is referred to as personification. After a time, users will normally gravitate
toward the use of codified knowledge, once a better and more complete contextual
understanding is gained. In light of this, a KM system must be flexible enough to meet user
search needs through both of these phases. This is addressed by the system model proposed
in this thesis, through the combination of high quality in taxonomy and ontology (for
codified knowledge), and support for identifying experts (for personification) within the
problem domain of health care fraud.
Expert identification is handled in two ways: firstly, through self-identification, and
secondly, through community ranking algorithms. Self-identification is supported through
user profile creation within the system, where the profile contains educational, occupational
and other background information that helps to establish trust among other users. Community
ranking allows users and other experts to rate knowledge contributions; as ratings increase, a
user’s reputation within the KM system’s community increases and the system calls attention
to this user’s ongoing contributions, highlighting them as “more valuable”.
There is little doubt that the proposed system would experience heavy use under both
the codified and personified cases. Jennex and Olfman (2006) discuss increased user reliance
upon person-to-person knowledge transfer increasing as complexity of knowledge increases
within a system. Health care-related knowledge is extremely complex and understood
differently by different user types; additionally, the proposed system seeks to include a broad
and diverse set of stakeholder roles. Despite the fact that users generally move from the
personification to the codification phases, this does not always need to be true, and is
dependent upon the characteristics and nature of the system and the domain in which the
system is operating. According to Jennex and Olfman (2006), the required contextual
information that must accompany knowledge in order for it to be relevant and applicable
becomes more difficult to capture as complexity increases, and in such cases, users may
revert back to the use of personification.
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Create Shared Context

Users, and the organizations and/or interests represented by those users, must
understand their internal world, their external world, and the interrelationship between these
environments. Enabling and encouraging open and engaged dialogue between users, and
ultimately user types, must be a key consideration; failure to do so will result in a system
with a large collection of data that is disconnected and, consequently, considerably less
useful.

Focus on the Future

Considerable data will be collected by the system, almost entirely consisting of data,
information and knowledge related to past events. However, it is important to keep in mind
that the purpose of the system is not to catalog history for history’s sake; rather, such
historical data should be captured and effectively leveraged for the purpose of predicting
future behaviors and tailoring anti-fraud efforts (whether in the form of law enforcement
investigations, legislative actions, private industry controls, or research) to be more closely
aligned with the dynamic nature of the problem domain.

Create a Knowledge-Friendly Culture

Jennex and Olfman (2006) discuss the importance of organizational support for KM
success, particularly with respect to managerial support, incentives, encouragement and
direction. To foster effective collaboration between different user roles within the system,
care must be taken to facilitate cooperation between diverse groups.

Appropriate Technical Infrastructure

Any implementation of the system must be undertaken using appropriate data
structures, database design, programming and sufficient technological resources, especially
in terms of hardware. Additionally, sufficient security controls must be put in place. Jennex
and Olfman (2006) discuss the need for an integrated architecture that allows for data
storage, data exchange, search and retrieval.
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EXTENDING THE CONCEPT OF A COMMUNITY OF

PRACTICE
As was discussed earlier within the literature review, some disagreement exists
among KM experts with respect to the formal definition of a community of practice. While
the literature reveals that these groups are often considered to be a collective of practitioners
in a particular field (a number of experts have made distinctions between a community of
practice and a community of interest), other experts (e.g. Wenger) have defined communities
of practice within a framework of the group’s characteristics, sense of purpose and the
dynamics surrounding the interactions of its members. Wenger, in particular, considers a
community of practice from the perspective of how work is accomplished through
collaborative efforts and, more specifically, along three primary dimensions: joint enterprise,
mutual engagement and shared repertoire. A key objective of the model system proposed in
this chapter is to serve as “virtual venue” to support the growth and development of a
community of practice that is consistent with, and is a natural extension of, the latter view.
In terms of mutual engagement, the proposed model creates an environment that supports
diversity through the enabling of complementarity (by bringing together parties with
different, yet equally important backgrounds and mental models) as well as distributed
cognition. In addition, by inviting diverse user types such as patients, providers and payers,
multiplexity (the concept of members being joined by ties that even include conflict) is
achieved; fraud is committed by members of each of these user types, however, each type is a
key stakeholder in the problem domain and each has information valuable to the others. Joint
enterprise, or the common objective that binds the group together and directs its efforts,
centers on the expansion of the knowledge base surrounding the dynamics of health care
fraud, waste and abuse. The concept of shared repertoire is well-supported through richness
of taxonomy and ontology (discussed in the following section of this chapter). The proposed
model and system facilitates perpetual growth of a shared repository of terminology and
jargon, techniques, concepts and, finally, models representing dynamic interrelationships.
The proposed model defines a system architecture that supports a dynamic community of
practice which exists to effectively create and transfer knowledge surrounding health care
fraud, irrespective of geographical and organizational boundaries. While Wenger’s work
heavily considers communities of practice within business organizations (his description of a
 77

claims processing functional unit is often cited in the literature) and the associated
managerial challenges surrounding nurturing and integration of these groups, this thesis
envisions a large, distributed network of individuals and organizational representatives
essentially functioning as a community of practice. Due to the availability of increasingly
powerful, and less expensive, computer and communications technology, it is argued that
such a group can grow and thrive in a purely virtual environment, where the group’s efforts
and the dynamics of members’ knowledge exchange are guided by a sophisticated,
distributed knowledge management system architecture.

MODEL TAXONOMY AND ONTOLOGY

It is recognized that the classification and relationship between system objects must
be designed in such a way as to be understandable and highly usable by all participants; this
presents somewhat of a challenge due to the diverse nature of the collaborating parties.
Participants of different backgrounds often use completely different taxonomies for their own
understanding of concepts and interrelations between such concepts, as well as in
communicating with their peers. Of the groups represented by the model, this taxonomic
chasm is certainly widest between physicians and patients, while that between physicians and
payers is the more closely aligned. This issue represents the most critical component of the
system architecture design.
Each system object is defined by its taxonomy and ontology, as well as through
metadata, or attributes. In terms of metadata, the following dimensions are used and are
common to all objects within the model:
Object Type: Denotes the type of object, such as a provider or payer document,
diagnosis, procedure, physician or physician-patient encounter.
Tags: Keywords that help users to locate relevant objects, categorize objects, and to
more easily understand object context.
Knowledge Type: Examples include patient experience, billing, lessons learned from
the field, advice on interpreting remittance advice and other documents, and
investigations/cases.
Contributor: Represents the system user whom contributed the knowledge object.
Time: Information related to creation and editing chronology of the object.
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The set of major objects supported by the system is depicted visually in Figure 7.

Figure 7. Major pre-defined object types supported by the proposed system.

An Encounter represents a patient visit to his or her primary care physician, or to a

specialist or particular facility. This could include a routine checkup, a consultation with a
specialist, or even a surgical procedure. An encounter is a set of several other knowledge
objects that describe the event; these include User objects (to represent the provider and
patient), Term (medical terminology/conceptual) objects representing Diagnoses and
Procedures performed, and Documents related to or arising from the event (from both the
rendering or billing provider as well as the patient’s insurer, or payer). Moving upwards in
the hierarchy, a patient’s Health Record is comprised of the collection of patient encounters.
Other major objects include Cases and Investigations, which represent finalized
healthcare fraud-related cases as well as ongoing investigations and audits.
As previously discussed, accommodating multiple and sometimes inconsistent user
taxonomies is a primary consideration in the model design. To facilitate this, diagnosis and
procedure objects are maintained in the database using the appropriate industry ICD-9, ICD-
10 and/or CPT (Common Procedural Terminology) identifier; these objects are visible and
accessible to users in a variety of ways and this association is not burdensome or restrictive
to the user, but allows a consistent method of internal data classification. Each diagnosis and
procedure object is associated with one or more alias tags, which provide a reference to the
object using language and vocabulary consistent with the differing taxonomies of the
system’s diverse user base.
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Diagnoses and procedures represent the information and knowledge that is most often
misunderstood, or which is understood differently among individuals and groups of different
backgrounds; further, these concepts are likely those of the greatest importance as they have
direct or indirect relationships with nearly every other object in the KM system. For example,
the ability to locate knowledge represented by, and attached to, these two object types is
critical to the understanding of provider billing statements and payer EOB documents. Table
17 shows an example of how a particular diagnosis is represented by the system.

Table 17. Representation of a Diagnosis Object by the Proposed System

Term (Type: Diagnosis)

Label Typical For Type

784.0 Payer, Provider Code Set/ICD-9

R51 Payer, Provider Code Set/ICD-10

Headache Provider Description

Migraine Patient Description

Head+pain Patient Description

cephalalgia Patient Description

As indicated by Table 17, a diagnosis may be known, or referred to, using different
terminology among different user types. Furthermore, different means of expression of the
same concept may be used among different types of documents within the health care
industry.

SYSTEM ARCHITECTURE AND OTHER TECHNICAL

CONSIDERATIONS
Areas of particular interest within the proposed system architecture are now
discussed. The selected components discussed in this section specifically relate specifically
to key considerations including security, privacy and data exchange between users.

“Hubs” for Organization and Granular Control

The system is designed as a collection of objects called hubs. Hubs can represent any
object, including medical terms, users, physician-patient encounters, EOB documents, or
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even a patient’s complete personal health record. Hubs are classified using the taxonomy
previously explained and will always possess one or more connections to other hubs.
Connections are formed both automatically and based on user tagging; network effects result
in increasingly rapid growth as the number of participating users and quantity of data within
the system grows.
An example of the hub-based architecture is shown in Figure 8. In the figure, the
reader will notice a bold, dashed line connecting a particular Procedure object, or hub, to a
number of Provider objects. This indicates a relationship between the objects; in this case, it
is a visualization of developed knowledge within the system wherein the same Procedure
(procedure code) has been used by several providers on billing statements or other
documents.

Figure 8. Example of hub-based architecture used to express

relationships between objects within the proposed system.

For many types of procedures, such as office visits (CPT 99213 and 99214, chiefly),
this is to be expected. All physicians will use these codes for all of their patients; which of
the two codes is used will only depend upon whether the patient is new or previously-
established with the physician’s practice. Depending on which particular procedure
represents this Procedure hub, further attention may be warranted.
However, extending this example to the KM system wherein the primary objective is
to identify potentially-fraudulent behaviors, it is necessary to consider the relationships
further. The bold, dashed line also depicts a relationship between all three of the providers
independent of the procedure object. Again, in the presence of other indicators and/or with
 81

additional data, the connections between these providers could be indicative of suspicious
referral activities and even suggest kickbacks (exchanges of monies or other things of value
for referrals). Dozens of high-profile health care fraud cases have dealt with such scenarios,
and in such cases, even the rendering of medically-unnecessary services (e.g. unnecessary
surgical procedures) is not uncommon.
As for how hubs and the connections between them are actually created, this occurs
as a result of user participation through sharing of personal health information, industry
knowledge, news stories, investigation data, and past experience in the domain. For example,
a user may elect to create a hub based on a recent visit to a specialist. Details provided might
include the date of service, name and location of the specialist, procedure and diagnosis
codes referenced in the patient statement, and the name of the user’s primary care physician
who referred the user, or patient, to this specialist. Another user may later add information
related to the same doctor(s) or procedures; at such point, a connection is automatically
formed by the system between all common elements of the information, thereby creating new
knowledge related to one or more relationships. If yet another user adds tags, or metadata, to
one of these two hubs, additional relationships may be identified.
One interesting characteristic of hubs is the ability of user-creators to define personal
and public pieces of the hub. Public pieces of the hub are visible to all other system users,
whereas personal pieces are only visible to the user-creator. However, relationship analysis is
still conducted by the system and connections formed in a manner that respects anonymity
through the obfuscation of all personally-identifiable information. This architecture takes
user privacy preferences into consideration, creating a safe environment whereby information
can be made public in a granular fashion, with the user-creator retaining the full extent of
personal control consistent with that user’s level of comfort in sharing. Relationships
identified between a hub’s personal piece and any other hub only indicate that a general
relationship exists between the two object types.

User Types
The KM system recognizes a number of user roles, or types. All of these types inherit
from a generic type, User, which represents all common attributes such as real name,
username, the collection of user preferences, location, demographics, background and
 82

industry or other affiliations. Specific user types consist of Patients (self-explanatory),

Providers (including primary care physicians, specialists, inpatient and outpatient facilities),
Researchers (academic researchers including college and university-level faculty and
students), Payers (insurers) and Government/Regulator types (including representatives of
government-sponsored health programs, regulatory bodies and law enforcement officials). As
discussed in the introductory chapter of this thesis, members of the general public (as
taxpayers) are key stakeholders in the combating of health care fraud, waste and abuse.
However, the reader will note that no such user type exists in the proposed model; this is
because a patient already represents a taxpaying member of the general public whom has had
at least one interaction with a health care professional and, consequently, possesses
information and/or knowledge to contribute as a system user.
It is argued that the user types specified by the system model constitute all
stakeholders within the problem domain and represent valuable sources of knowledge which
should be captured via any and all reasonable means.

Peer-to-Peer (P2P) Network Architecture

One unique aspect of the proposed model lies within its massively distributed nature.
The system represents an example of a hybrid distributed knowledge management system,
where a peer-to-peer (P2P) network architecture is supported along with a more conventional
central data repository. As an additional method of encouraging patient participation by
taking privacy concerns into careful consideration, patients can share data for analysis
without electing to store data into the central repository permanently. In this case, data from
such sources is available temporarily, whenever the user is online. A central discovery and
mapping server is employed, which retains no health information but rather acts as a simple
tracking system for the central site/repository and for other P2P user clients. To gain a better
understanding of the mechanics of such a tracking system, the reader may wish to consider
the way in which torrent trackers operate.
Information and knowledge made available to the network via P2P clients is in the
form of PHR (personal health record) data entered by the user into a free client available for
download from the main site of the proposed KM system. As such, all information is stored
 83

on the client side, and settings are available to indicate which pieces of information will, or
will not be, shared with the rest of the network.

TOWARDS THE IMPLEMENTATION OF A SYSTEM BASED

UPON THE MODEL
Most existing KM systems are quite similar, in terms of user interface and navigation
characteristics, to online social networking sites or portals. This style of presentation has
been the norm to date, and this author can see no compelling reason to deviate with respect to
the user experience in general. However, this thesis envisions extensions to, and a stark
departure from, the prevailing model in several ways for the system proposed in this thesis.
To maximize information and knowledge inputs to the system, its implementation
must be handled in such a way as to facilitate efficient, flexible and creative capture of data.
To this end, the system should be able to accept both direct as well as automatic input. In
terms of patient contribution of data, a means of directly entering information into the KM
system (through a web form, for instance) would be necessary and the absence of such
functionality would be strange, to say the least. However, there are other available sources of
patient data, information and knowledge. Large, online social networks already exist which
are focused on general health and wellness, and additionally, networks have been created as a
place for discussion and sharing revolving around specific diseases and conditions. The KM
system described in this chapter should be able to access information from these networks
(via various methodologies, ranging from HTML screen scraping to retrieval of data using
XML web services) with explicit permission from the user whom created or posted the data.
The same techniques could also be used to capture data from online PHR (personal health
record) services, which have been growing in popularity and have been created by large and
small software vendors as well as by payers of all sizes and types. In the patient-type users’
preferences screen within the proposed system, users would specify which other sites and/or
services that they would agree to share data from, with specific controls to dictate allowed
levels of access based on specific settings.
As the quantity and quality of data present within the system grows, and as additional
connections and relationships become developed, the system could serve as the core of a
powerful decision support system, accessible by payers’ claims adjudication systems. This
integration could occur in real time via XML web services, using a payer subscription model.
 84

While the shortcomings of DSS-based attempts at fraud detection have been previously
discussed, the approach discussed here would likely produce considerably better outcomes,
due to the fact that the data within this DSS is dynamic, continuously evolving.

FINAL REMARKS ON THE PROPOSED MODEL

In addition to the need for increased patient participation in anti-fraud efforts, close
and effective cooperation between payers will also be a necessary ingredient to the proposed
system’s success and, moreover, to the outcomes of anti-fraud activities in general. It is the
opinion of this author that such cooperation is plausible; while some hesitation may exist at
the present time, payers will likely realize in the near future that the financial benefits of anti-
fraud cooperation with other payers (even competitors) are compelling. This will be thanks
to, in no small part, the significant increases in fraudulent activity projected to impact the
health care industry over the next 3-5 years.
Even minor discrepancies and peculiarities within submitted claims data, other
transactions and correspondence from providers to payers can be indicative of a significant
fraud problem. For example, two claims indicating the same particular rendering provider but
shown with different NPI (National Provider Identification) numbers, or two claims for the
same member but with different dates of birth or other demographic attributes can be an
indicator of fraudulent activities. Since the majority of providers are contracted with multiple
payers (for example, a provider may see patients insured by a combination of Medicare,
Medicaid, Blue Cross Blue Shield and United Healthcare) there is significant value in
reconciliation of such common information among payers to identify potential irregularities
and take appropriate action.
 85

CHAPTER 6

SUMMARY, RECOMMENDATIONS AND

CONCLUSIONS

At this time, the paper takes the opportunity to reacquaint the reader with the
fundamental research question and purpose of the work, as well as to summarize the study
process, key findings and implications for future research related to the problem domain.
The central research question to be addressed by this thesis revolved around the
identification of barriers to participation by patients in health care antifraud activities; such
activities might range from simple reporting of suspected fraudulent conduct, all the way up
to participation in an online social network whose purpose is to collaborate on antifraud
study and enforcement. In order to determine as many of these barriers as possible, and at the
same time, to assess what variables may directly influence willingness to participate, an
extensive literature review was conducted, followed by the design and subsequent
distribution of a comprehensive survey instrument. With specific respect to the literature
review, special emphasis was placed upon knowledge management (KM), through the
inclusion and evaluation of KM research and prior studies.
A thorough review of the literature revealed that key attributes to be considered, with
respect to general participation, should include individuals’ perceptions, common vocabulary
or some other ability to communicate in the language of the domain, awareness and interest.
In terms of individuals’ perceptions, such characteristics include whether or not the
individual considers his or her knowledge to be a “public good”, a sense of moral obligation,
desire for establishing oneself as an expert within a particular domain, level of trust between
participants in a community setting, and additionally, self-assessment of his or her degree of
domain expertise.
The survey instrument was developed with the above findings in mind. The
instrument sought to capture insightful data based on an assessment of patients’ current
understanding of health and medical terminology, problem awareness and interest, attitudes
towards patient health information privacy, and experiences in terms of sharing. Responses
 86

obtained from this survey were generally as expected; however, analysis of the data using the
hypothesized model and linear regression methodology did not produce the anticipated
results and conclusions, in terms of demonstrating a significant positive correlation between
willingness to participate (in health care anti-fraud activities, for this study) and the major
variables selected. In considering and assessing the possible reasons for the outcome of the
study, this paper concludes that variable modeling, question format and weighting were the
most likely factors affecting the results. In terms of variable modeling, it is extremely
difficult to use survey questions where the concepts of willingness and ability are derived
from the manner in which certain questions were answered, instead of asking participants
outright how prepared they might feel to actually become involved.
The most ideal approach and one that may well have produced results consistent with
the study hypotheses would be one in which actual, previous participation in health care anti-
fraud activities are assessed and modeled as the dependent variable, with the factors
measured in this study once again used as the independent variables. However, based upon
previous research, opportunities for patient participation in this domain (due to the
combination of intentional exclusion and inability to effectively participate) have been
disappointingly limited. Thus, it would have been, at this time, infeasible to collect such data,
both in terms of identifying a population of willing respondents of suitable size, as well as
taking appropriate steps to mitigate the effects of population self-selection.
Despite unfavorable results of the analysis, it is argued that the proposed KM system
model described in the previous chapter has merit and may, in fact, constitute a compelling
framework for the development of a KM system that can positively impact the efforts of
private insurers, government and regulatory entities towards combating health care fraud.
While the analysis of this study’s survey results did not produce the expected results, the
existing literature is highly suggestive that such a system could be an effective ingredient in
the anti-fraud battle.
It is the intention of this author, building upon lessons learned from this study as well
as review of the relevant literature, to continue research within the problem domain. As
previously described, primarily within the first and second chapters of this thesis, the
problem of health care fraud presents enormous economic and social problems. It is a
 87

problem that has been largely ignored by academic research, yet a problem that demands
greater attention from public and private research efforts.
 88

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APPENDIX

STUDY QUESTIONNAIRE
 94

Health Care Fraud: Consumer Awareness and Attitudes

This survey and study are being conducted by Matt Strandberg, a candidate for the degree of
Master of Business Administration at San Diego State University.

This study is being conducted in order to assess the following:

 Current awareness and attitudes surrounding health care fraud in the U.S. health care
system
 Familiarity and understanding of medical terminology and code sets
 Interest and ability in terms of potential involvement in combating health care fraud

All interested persons over the age of 18 are eligible and encouraged to participate. However,
please understand that your participations is VOLUNTARY. You will be asked to complete a
short survey consisting of questions of a non-sensitive nature; estimated time for completion
is between five (5) and ten (10) minutes. All participants will be anonymous and
confidential; no personally-identifiable information is requested or desired. No compensation
is offered for participation.

If you have any questions or concerns about this research or the survey, please contact the
SDSU Graduate Business College, at (619) 594-8073. For questions pertaining to your rights
as a research participant, please contact the Institutional Review Board (IRB) via its email
address: irb@mail.sdsu.edu. Thank you for your interest in participating in this study.

Question 1
The last bill that I received from my doctor was easy to understand. (circle one)

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 2
The last Explanation of Benefits form that I received from my insurance company was easy to
understand. (circle one)

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
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7 - Strongly agree

Question 3
Are you currently a Medicare beneficiary? (yes/no)

Yes
No

Question 5
Match the following terms to their respective definition, synonym, medical billing code or
related term. Please do not use any references or otherwise “look things up” – a reliable
measure of understanding is important to the study.

A = Common cold
B = Health Care Procedural Code Set
C = Procedure Code
D = Swelling
E = Office Visit
F = Course of Action to achieve a result
G = 784.0
H = Care provided to improve a situation
I = Code set used for diagnosis codes
J = Label for medical condition/disease
K = Acute Nasopharyngitis
L = 99214

A B C D E F G H I J K L
a. Procedure
b. Diagnosis
c. CPT Code
d. Treatment
e. 99213
f. ICD-9 Code
g. 460
h. Acute Nasopharyngitis
i. HCPCS
j. Headache
k. Doctor visit for established patient
l. Inflammation

Question 6
I usually understand my doctor’s instructions and explanations. (circle one)

1 - Strongly disagree
 96

2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 7
I consider myself involved and interested in my personal health and health-related matters.
(circle one)

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 8
I wish that I was more involved in my own health. (circle one)

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 9
What would make it easier for you to become more involved in your own health? (circle as
many options as apply)

A – If I knew more medical terms

B – If my doctor could/would spend more time with me
C – If I understood my condition or disease better
D – If doctors would speak in language that I can understand
E – If I knew more about using the internet
F – If I had health insurance
G – Other (please specify)

Question 10
I believe that fraud, waste and abuse are huge problems in the U.S. health care industry.
(circle one)
 97

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 11
Who do you believe perpetrates the majority of fraud in the health care industry?

A – Insurance companies
B – Patients
C – Doctors
D – Regulators and government
E – Other (please specify)

Question 12
I wish I could do something [or do more] to reduce health care fraud. (circle one)

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 13
Have you been involved in health care anti-fraud efforts in any capacity? [Including
participation in a workshop, membership in a group, reporting fraudulent behavior,
examining any documents for possible signs of fraud, subscribing to a fraud-related
newsletter, etc.] (yes/no)

Yes
No

Question 14
If I believed my doctor was engaged in fraudulent billing and/or other behaviors, it would
bother me. (circle one)

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
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6 - Agree
7 - Strongly agree

Question 15
If I had knowledge of fraudulent activities being committed, I would report it to the
authorities, my insurance company, and/or some other party. (circle one)

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 16
What do you feel is the biggest challenge to combating health care fraud? (select as many as
apply)

A – The problem has become too large and/or complex to handle.

B – Patients/consumers don’t have enough information.
C – Insurance companies don’t care.
D – Patient’s don’t know what to look for or how to spot it.
E – Insurance companies don’t care
F – Nobody asks patients for input/suggestions.
G – Other (please specify)

Question 17
What is your age range?

A – 18-25
B – 26-35
C – 36-45
D – 46-55
E – 56-65
F – 66-75
G – 75 or older

Question 18
What is your level of education?

A – High school diploma

B – Some college
C – Bachelor’s degree
D – Some graduate work
E – Master’s degree
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F – Doctoral degree

Question 19
Are you a healthcare professional or involved in healthcare in any manner? If so, what is
your capacity/profession?

A – Medical Doctor
B – Nurse
C – Hospital administration
D – Medical billing
E – Information technology related to healthcare
F – Insurance payer
G – Government/regulatory
H – Other (please specify)

Question 20
I am comfortable with using the internet. (circle one)

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 21
I am comfortable using a computer for general tasks. (circle one)

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 22
What city and state do you reside in?

Question 23
With legislation related to the healthcare reform bill of 2010, the ability for an insurer to
deny coverage of patients with pre-existing conditions will be eliminated. This protection
makes me feel more comfortable in sharing health data for research purposes.

1 - Strongly disagree
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2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree

Question 24
I have shared, or would feel comfortable in sharing, personal health information (even
anonymously) or seeking advice on a health-related matter via an online web site/social
network.

1 - Strongly disagree
2 - Disagree
3 - Somewhat disagree
4 - Neither agree or disagree
5 - Somewhat agree
6 - Agree
7 - Strongly agree