The Economic and Human Cost of Fraud, Waste and Abuse in the Health Care Claims Processing System.

The Economic and Human Cost of Fraud, Waste and Abuse in the Health Care Claims Processing System.

The main goal of a proactive data analytics solution should be to interrupt health care fraud, waste and abuse as early in the cycle as possible to save money for health care insurance companies and their customers. An aggressive, proactive initiative will also ensure the integrity of the provider community and most importantly help protect patient safety.

One of the most egregious cases of health care fraud involved Farid Fata, MD – Oncologist and Hematologist who practiced in Michigan. He was named as a “Top Doc” and was well respected by his peers. This professional recognition didn’t satisfy his quest to make as much money as he could from health care fraud and at the peril of his patients

Dr. Fata billed Medicare and private insurers for services to include chemotherapy and expensive PET scans rendered to patients who either did not have cancer or whose cancer was in remission. One of the worst examples of his greed was demanding that a woman bring her extremely ill husband to his office first before taking him to the hospital. The man was unable to get out of the car since he was so ill. However, Dr. Fata administered chemotherapy to him and billed his medical insurance. The man later died in the hospital. The indictment listed 550 people who were medically victimized by Dr. Fata to help him steal $17 million dollars from an already fragile health care system.

http://www.freep.com/story/news/local/michigan/oakland/2015/07/10/fata-sentence-handed-down/29952245/

Many of Fata’s assets were frozen when he was arrested. A number of wrongful death suits were filed so the assets were held pending restitution awards granted as a result of those suits. In addition, investigation by authorities determined that Dr. Fata diverted a considerable amount of his ill-gotten profits to Lebanon to build a palatial residence.

It is crucial that payers stay ahead of the fraud game. Unfortunately, only about 10% of all money lost to fraud is recaptured by the payers. This anemic result has a direct impact on the payers; employers who are struggling to provide quality health care coverage to their employees; and most importantly resulting in escalating premiums, co-pays and potential loss of coverage for individuals being treated by the likes of Farid Fata MD.

Traditional methods of data analytics of health care claims are focused on rules based or structured models and algorithms that detect aberrancies after claims have been paid; the pay and chase scenarios. WhiteHatAI is a new company to the table raising the bar with its Centaur product which incorporates machine learning and artificial intelligence to provide an advanced, pre-pay solution to detect indicators of health care fraud, waste and abuse in real time. So how does this advanced approach benefit health insurance payers and their customers? At a minimum, it saves the payer money but more importantly early detection of aberrant claims can help to save lives. There is clearly an economic impact which the state of the art WhiteHatAI Centaur stands ready to address. However, the sad part of the efforts by those who commit health care fraud is the human tragedy they leave in their wake. Dr. Fata was sentenced to 45 years in prison but it is a small reward for those who lost their loved ones or whose health is permanently damaged by his quest for wealth.

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