Advancements in the Discovery of Healthcare Fraud

It is estimated that healthcare fraud costs tens of billions of dollars per year. Even though insurance special investigators work tirelessly to curb this epidemic, it can be quite challenging to stay ahead of the curve with constantly evolving technology and intelligence. So what is currently being done? Let’s take a closer look.

Staying Ahead of the Game

Up until recently, health care fraud investigations were almost always handled after they occurred; usually a result of a tip submitted by an employee that noticed something amiss during claims processing. It was solely dependent upon someone paying close attention and having the confidence to report it, which was still quite costly because once a claim is paid out, it’s difficult to get all of that money back. With the development of analytics technology, investigators are now able to get ahead of some fraud by looking at claims data and applying rules and queries to pick up on outliers and suspicious details that can then be looked into more in-depth.

What Information is Analyzed?

While there’s a variety of information to be looked at, the most important pieces include provider history, claims data, and member eligibility information. When you add data for pre-authorizations, prescriptions, lab requests and call-center records, it only enhances the analysis. With technology advancing, it’s becoming much easier to stay on top of these things in real-time. However, there’s still a long way to go in widespread development.

How Can AI Enhance Detection?

Combining big data and AI can assist with anti-fraud efforts significantly. Big data provides access to a great deal of information on a real-time schedule and applying AI to the data allows us to utilize machines for more advanced, accurate analytics much quicker than usual. With this process, we are able to use risk scoring VS traditional rules-based analysis, it allows for us to broaden our view while also reducing false positives. Additionally, the quicker speed allows for easier evaluation of suspicious claims prior to payouts.

How Do Workflow and Collaboration Tools Enhance the Process?

Collaborative tools provide the ability to coordinate evaluations efficiently with other experts and help to reduce the amount of time each investigation takes. Effective workflow saves time and money through streamlining every step of the investigation. This is especially important due to increasing levels of healthcare fraud.

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