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...

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...