Healthcare is one of the most fundamental and basic rights involving humans all over the world. Countries economy can get severally paralyzed if its citizens are not getting enough and appropriate healthcare services. It is very important to focus our resources to solve this problem to provide affordable healthcare to everyone.

Introduction to FWA ( Fraud, Waste and Abuse )

Waste of money, time and resources due to inaccuracy  or transgression at any stage of the system is nothing but FWA. FWA is illegally using health insurance & lying with the knowledge that result in someone else’s profit. The payments or services which are unnecessary cost to health programs or institution and are not medically necessary.

Impact of FWA on American Healthcare

American healthcare is getting so costly that 2017 spending on healthcare was almost similar to overall GDP of Germany for the same year and its ballooning to nearly $6 trillion in next less than 2 decades. A large portion, around 20%, of this accounts to FWA ( Fraud, Waste and Abuse). 

Opioids and other Narcotics frauds are the most common among them. These kinds of frauds are accounting and costing $2 billion dollars to medicare economy. A recent case involving this have uncovered 600 defendants across 58 districts.

Healthcare frauds are costing way more for common people to bear. Low income families, veterans and students are getting affected in worst possible ways. For a country who identify itself as the most prosperous country in the world, rising healthcare cost is standing as a very big monster to defeat.

Let me define you the overall structure of this monster. This monster will be standing on two legs namely (Detect and Diagnose). To solve a problem, we first need to get defensive to detect the problem first and find a cure for it (diagnose). After that, we can go offensive by reducing and preventing future FWA’s.

Solutions designed by WhiteHatAI

It is now time to raise a monster to fight a monster. To solve a problem, we first need to get defensive to detect the problem first and find a cure for it (diagnose). 

  • About Detect which can be done by auditing and verifying claims and investigating the bills and prescriptions. Detection can be done by analyzing standard clinical procedure and finding outliers by using descriptive and predictive analysis.
  • Diagnosis can be done by analyzing missing information and gap in the medical data, inefficiency in claim adjudication system and data quality.

Let me just walk you through the process which WhiteHatAI undergoes to detect and diagnose FWA.

  • Use of predefined rules and an overall data intake structure make sure that the claim presented for audit have sufficient information to pass the processing system and is following all the basic rules without which claims can come back for resubmitting which is another whole big issue.
  • Using duplicate identification process to flag out certain or potential duplicates which can later be handed over to auditors for further investigation.
  • Spatial clustering techniques are used with latest algorithms and techniques to flag out any suspicious activities involving amount and frequency of claims.
  • Better neural network techniques used to train and detect fraud with minimal human intervention.
  • Using natural language processing technique to understand human auditor feedback about a claim and try to integrate the reason from next time whenever it finds claim of that type.

The other side of the solution is going offensive, means trying to prevent fraud from happening and helping SIU (Special Investigation Unit) in identifying fraudulent claims

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