Why Health Insurance Fraud Is Bad for Everyone | Insurance business America
And can AI help curb health insurance fraud?
Life & Health
By David Saric
Some may think of health insurance fraud as a victimless crime, but it hits Americans where it hurts: their wallets and the quality of their care.
That’s what Karen Weintraub (pictured), president of Healthcare Fraud Shield, says.
“If you look online, particularly through government reporting from Medicare and Medicaid, [health insurance fraud] is over $100 billion, but when you start including commercial data, you’re probably looking at well over $200 billion in potential fraud, waste and abuse,” Weintraub said.
Fraudsters involved in health insurance fraud could use the proceeds to buy larger homes, airplanes and other luxury goods. Meanwhile, their fraudulent profits resulted in “higher rewards for other people,” Weintraub said.
Health insurance fraud can also jeopardize the quality of patient care.
“You’re treating a patient for something they don’t need and can actually harm them,” Weintraub said. “In the news, there was a hematologist/oncologist named Farid Fata who was treating patients as if they had cancer and actually giving them chemotherapy, which caused a whole host of problems.”
In 2015, Detroit doctor Fata was sentenced to 45 years in prison for his role in a health care fraud scheme in which he administered medically unnecessary infusions or injections to 553 individual patients and bilked Medicare and private insurance companies to the tune of $34 million US dollars amounted to fraudulent claims.
In an interview with Insurance Business, Weintraub talked about how the adoption and use of AI can contribute to health insurance fraud and, conversely, how this technology, if implemented correctly, can also solve the historic problem of detecting fraud, waste and abuse.
How providers can use AI to commit health insurance fraud
The AI hype describes it as a transformative tool that can streamline and expand a company’s internal and external operations, but it could also serve as an ally to insurance fraudsters.
“From a provider perspective, I see more [use of AI] – They may be using AI to create medical records, making it more challenging for those of us who analyze data and review medical records to determine whether services are appropriate,” Weintraub said. “Now we are looking at AI to detect AI.”
One of the main concerns when adopting AI or other generative language models such as ChatGPT is the need for greater scrutiny of data hygiene and ensuring that the information entered and extracted by these technologies is accurate.
“Generative AI would be what providers would use to generate content in their medical records – there are pros and cons that it can certainly be a time saver, but it still needs to be proven to be completely accurate,” Weintraub said . “Not only are records created that may or may not represent actual services provided, but they can also be completely fabricated, resulting in what are known as ‘hallucinations.’
How AI can be used as a tool to detect health insurance fraud
AI poses a threat and challenge, but also offers potential benefits.
“I’ve seen a lot of health care providers come and go,” Weintraub said. “Analytics is a great technology, but a truly deep understanding of the complexities and nuances of healthcare varies by payer, state, industry and product type, e.g. E.g., Medicare versus Medicaid versus commercial plans, and within commercial plans there are so many different variations and coverage there is no consistency.”
AI that is able to capture these nuances of data and analyze it on a much larger scale could prove to be very helpful in taking all of these complexities into account and finding out things that the human eye can’t necessarily see.
“The human eye can look at the results of the AI and see whether it makes sense or not,” Weintraub said. “If the data isn’t right, then the AI output isn’t right – that’s important to know, and if some customers have dirty data, that will impact the results of all analyses, not just the AI.”
Weintraub is optimistic that AI can still be of great help if approached with caution and control.
“By using our own AI to detect data nuances and potential fraud, we found things that our traditional targeted analytics didn’t identify,” Weintraub said. “It can definitely find pockets of things that pop up or things that we’re just not aware of,” she added.
Weintraub has increasingly seen various companies establish AI governance committees to ensure data is used ethically, responsibly and appropriately.
“I think there will be a little more oversight, not just among payer organizations and insurance companies, but also among the providers that use them,” she said.
Do you think AI can be used to combat health insurance fraud? Sound off in the comments.
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2024-02-02 15:58:14
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