June 27 2016 | 0 Comments | 299 reads Average Rating: 3.4

Want to win the fight on fraud, waste and abuse? Get ready to go "all in"

by Rodger Smith in Payment Integrity

Healthcare fraud waste and abuse is big. As in hundreds of billions of dollars per year big. That’s why healthcare payers need to go big or go home in the fight against what’s become an unfortunate nemesis.

The challenge:

How can your payer organization go beyond what it is currently doing to combat fraud? Of course, as with anything so big, that answer is complex, and dependent of factors including your organizations unique processes, what populations it serves, and what area of the country it operates in. Still, you have to start somewhere. Here are four strategies that you can adopt to push your efforts beyond the traditional manual methods that most payers use to combat fraud:

#1: Leverage analytics that provide more punch

Advanced big data analytics that digest many different data sources can enable your organization to identify and analyze different types of suspect claims. And, with the best analytics you won’t be chasing down nearly as many dead-end trails – as these techniques and processes are capable of eliminating many false positives. The end result: Your scarce resources can focus their efforts where they are most likely to yield results.

#2: Power your efforts with more than just claims data

Yes, yes, claims data is the foundation since it is where the money is paid – but you need to look at more than just claims if you truly want your fraud fighting efforts to succeed. Try adding some demographic, geographic and other data about your members and providers to the mix – and you’ll be uncovering – and more importantly stopping more fraud waste and abuse.

#3: Know who your providers hang with

“You’re only as good as the company you keep.” Well, payers might want to take that axiom to heart when investigating providers. After all, if Provider A is involved in improper billing, it is not uncommon for other providers with which they associate to also be engaged in bad behavior. So, it would behoove you as a payer to start using advanced analytics to discover links between multiple providers. Information on shared locations, corporate ownership, billing and management companies, social media interactions of physicians and staff, common pools of patients can reveal whether other physicians, pharmacies, radiology centers, home infusion agencies, etc. are engaged in a broader pattern of referral and collusion.

#4: Load your lineup with the right players

No matter how advanced analytics are, however, uncovering improper payments also requires experts who understand how to digest and attack what the computers spit out. So bring in the ringers: Nurses who can see unusual or suspect patterns in medical records, law enforcement officers who understand criminal behavior, claims adjustors who see understand the ins and outs of payment policies, contracts, CPT and HCPCs codes, and actuaries who can look at mountains of statistics and quickly zero in on anything suspect.

These four strategies will get you started. Can you think of any other strategies that payers can take as they muscle up to fight fraud?

Rate this Article:

Average: 3.4 (10 votes)

Rodger Smith
SVP, Payment Integrity

Rodger has over 16 years of operational and industry experience in healthcare, handling matters involving provider contracting, claims operations, provider and member dispute resolution, industry regulation, fraud, waste and abuse investigation, and Payment Integrity.

Read full profile and other posts |

Log in to post comments



Arun Rangamani
VP, Payment Services Delivery Leader

Ben Steverman
Chief Technology Officer

David Hom
Chief Evangelist

Jodi Siegel, MSHI, BSN, RN (Guest Author)
Director, wellness and care management

John Pagliuca
Vice President, Life Sciences

Lalithya Yerramilli
VP, Healthcare Solutions

Lesli Adams, MPA (Guest Author)
Director of Population Health Strategy, Oracle Corporation

Linda Pantovic (Guest Author)
Director of Compliance & Risk Adjustment, Scripps Health Plan Services

Mark Feeney
Life Sciences Consultant

Monique Pierce
Vice President, Business Optimization

Nayfe Faillace
Chief Compliance & Privacy Officer

Nicole Stec (Guest Author)
Senior Well-Being Manager, Banner Health

Priyanka Rajkumar
VP - SCIOXpert and Solutions, Analytics

Rena Bielinski
SVP, Strategic Accounts

Rodger Smith
SVP, Payment Integrity

Rose Higgins
SVP & GM, Data and Analytics

Subha Vaidyanathan
VP, Technology and Data Management

Taryn Bevilacqua
Compliance Director


Sign up to receive the latest SCIO news & insights, industry updates, event updates and more, right in your inbox.