Keeping Healthcare Funds—and Patients—Safer

Tim Delaney came to MITRE in 2016 with a wealth of experience in serving the United States—in the Army, then with the Federal Bureau of Investigation. As the Program Performance & Integrity department manager in the Health FFRDC, he oversees a team of experts in healthcare program fraud, waste, and abuse—a particularly complex challenge.

The healthcare system is filled with wonderful, caring people who are in it for all the right reasons. But there’s a sinister element in every corner that’s looking to steal money.

There are licensed medical professionals, trained business executives, and just wily con artists who are out there every day looking for a new vulnerability. I’ve worked on cases across the spectrum of healthcare delivery. I’ve seen a pharmacist dilute cancer drugs for his customers who did not recover as they should have, a surgeon performing unnecessary open-heart procedures, and people openly selling your health information for a quick buck.

The billion-dollar loss cases make me mad, as a taxpayer. But it’s the patient harm cases that really make me want to get up and go to work each day.

Fraud Prevention: Saving Money, Saving Patients

Healthcare continues to take a larger and larger percentage of our budgets, and program integrity is crucial in keeping costs down.

Our department is relatively new. In the summer of 2020, the Health FFRDC pulled together a “been there, done that” team with experience across a range of federal, state, and private insurance programs to support our healthcare sponsors. Together, we possess the expertise to address fraud, waste, and abuse in the constantly evolving healthcare industry.

In our work, our goal is to ensure that as many dollars as possible are going to healthcare—not stolen or spent in the wrong way, or on the wrong thing. It’s been estimated that a good integrity program can return $7 for every dollar spent up front.

Identifying Vulnerabilities in Federal Programs

The number-one goal of any integrity operation program is to prevent money from being stolen in the first place. Working with our sponsor on MITRE’s Vulnerability Management Project, we’re helping to do just that.

Our team includes accountants, former federal agents, analysts, software engineers, and professionals with other deep program experience. They identify weaknesses in our federal programs, and the team reports them to the Vulnerability Collaboration Council. Working with the Centers for Medicare & Medicaid Services (CMS) Center for Program Integrity on Vulnerability Management, we examine the different programs under the CMS umbrella—Medicare, Medicaid, and potentially with the federally facilitated and the state-based healthcare exchanges—to identify areas that may be susceptible to fraud.

When we set the mission and vision for the department, we focused on the holistic approach to program integrity. That includes ensuring the right data is used in making a claim. The information needed will be available for audit or investigation. The process has measurable integrity. The outcomes of the system are built and managed with as few vulnerabilities as possible and with equity in mind up front.

The Secret Lives of Accountants

I was one of the first FBI agents to begin working in the field of healthcare fraud. I’m an accountant by trade—the FBI has historically used accountants to work white-collar crime cases.

At the start of my career, I worked in bank fraud. When the FBI started to receive funding under the Health Insurance Portability and Accountability Act of 1996, many of us special agent accountants were transferred to healthcare fraud. I’m considered one of the “plank holders” who worked to build the program and was actively involved with the Bureau’s healthcare fraud program for more than 20 years.

When I was eligible to retire from the FBI, MITRE was an attractive choice. I could continue serving my country as I had in the Army and the FBI and continue the mission that I’m passionate about.

The Bottom Line Is CareWill we ever completely solve the problem of fraud? It’s hard to say, because some seriously intelligent people out there are just looking for ways to exploit the system.

It always amazes me to see people who have worked hard to earn a specialized degree and become licensed in a field—and throw it all away for greed. MITRE’s healthcare fraud work will continue to evolve along with the healthcare industry, rising to meet our sponsor’s challenges.

—As told to Nancy G. Romps

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