Detecting Fraud and Abuse in Healthcare
Dr. Michael Nelson, Equifax VP of Healthcare Strategy and Business Development, recently participated at the AHIMA CDI Summit in a panel discussion on “Leveraging Data and Analytics to Detect Fraud and Abuse in Healthcare.” The panel was moderated by Jennifer Covich Bordenick, CEO for the eHealth Initiative.
In a white paper published last year, the eHealth Initiative stated:
The use of analytics can help to eliminate false positives, or the inaccurate indication of fraud or abuse, to ensure that only truly fraudulent or abusive cases are flagged. First-generation predictive models, which use demographic data and historical financial data to predict risk, use traditional parametric statistics to identify atypical behaviors or billing patterns by the provider.
The enhanced quality of care and cost savings the latest public health policies aspire to achieve require security, quality and transparency in patient, provider and payor information. Effectively fighting fraud requires an integrated strategy. Payers need to know if applicants for insurance or reimbursement are who they say they are and are eligible for Medicaid, premium subsidies or reimbursements. The ability to combine robust data and predictive analytics creates the solution necessary to proof an identity and to also verify eligibility claims like professional credentialing, income level, and insurance.
The AHIMA CDI Summit is the premier industry event dedicated to leading the documentation journey and exploring the challenges presented by today’s complex healthcare environment. The National Council on Data and Analytics discusses how data and analytics can support the detection and prevention of fraud and abuse in healthcare. This presentation focuses on how data and analytical methods can be leveraged to minimize fraud and abuse for payers, providers, and other healthcare stakeholders.
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