Low Integrity Medical Claims

Low integrity medical and pharmacy claims are on the rise.  You probably have seen a recent article or two about health care workers who couldn’t resist the lure of additional income.  Some of these perpetrators milk the system in the belief that claims are too small and/or too confusing for anyone to sort through.

Some high-profile perpetrators of large operations are getting caught.  For instance, a businessman in New Port Richey, FL recently was convicted of a pharmacy scheme that generated more than $100 million in ill-gotten gains from 2012 to 2015.  Kudos to the human crime stoppers who brought this scheme to an end.  However, it leads one to ask why this went on for so long, undetected and undeterred.   Part of the explanation might be found in the limitations faced by authorities when sophisticated thieves hide amid legitimate channels of insurance reimbursements.

In this case, the pharmacies submitted fraudulent reimbursement claims for prescription compounded medications, chiefly pain creams and scar creams, to private insurance companies, Medicare and TRICARE.  Fortunately, help is on the way.  New artificial intelligence algorithms are being developed which can see patterns of fraud among millions of claims.

In a cost-effective way, this AI can find even modest fraud schemes and stop the low integrity (and zero integrity) claims much earlier in their lifecycle.  Some of these new methodologies can detect the errant claims and make sure they don’t get paid.  Since possession is 9/10ths of the law, a system that can dry up sources of funds before they get to the criminals is a much more effective way to shut these schemes down.

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