Posts

Quantifying the Ritual Fraud Beneath Compliance Theater: Government Contracting 101

-
Image
“They didn’t just break the rules. They turned the rules into rituals— then hollowed them out and wore the shell.” The System Wears Lipstick You know the look. A federal contract labeled “Women-Owned Small Business.” A shiny press release. A prime contractor with no real infrastructure. A subcontractor doing 80% of the work—but getting none of the accountability. And behind it all? The same old players in new costumes. This isn’t a one-off. It’s a  pattern . A  ritual . A multi-billion-dollar game of hide-the-prime, dress-the-shell. And we’ve given it a name:  pass-through theater . Total Addressable Misconduct (TAM): A Market Sizing of Fraud We talk about corruption as if it’s intangible. Invisible. “Unmeasurable.” But if you can measure a market, you can measure a fraud. So let’s run the numbers. That’s not a rounding error. That’s an economy. Over five years?  Nearly $100 billion  in what we now call  Total Addressable Misconduct. Ghost Labor & Ritua...
Read more

Revenue Cycle Management (RCM) Companies: Exploiting Patient Data and Billing Codes for Profit

-
Image
  RCM-Related Fraud Schemes and Official Findings Upcoding:  Upcoding is the practice of billing for a more severe or expensive service or diagnosis than what was actually provided, in order to inflate reimbursement. For example, a routine office visit might be billed as a complex visit, or a minor diagnosis coded as a major complication. Upcoding has been flagged by regulators as a persistent problem. A 2021 HHS Office of Inspector General (OIG) analysis found hospitals increasingly billed inpatient stays at the highest severity level (nearly a 20% increase from 2014–2019) – a trend OIG warned was  “vulnerable to inappropriate billing practices, such as upcoding” . OIG noted that over half of those high-severity claims were qualified by only one major complication or comorbidity, suggesting  “billing at a level that is higher than warranted” . In response, OIG urged Medicare to target reviews at hospitals and diagnosis codes prone to upcoding. Upcoding is illegal un...
Read more