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Abuse and fraud within healthcare systems such as Medicare and the UK National Health Service, is rife. Millions of dollars are lost each year because of fraudulent claims and administrative waste. For every dollar that is frittered away, a patient loses out. Tackling the abuse and misuse of healthcare systems needs to be a priority, so how technology systems can provided by companies such as the Financial Recovery Group help?
Fraud happens at many levels. In the case of Medicare, physicians deliberately invoice for services they have not offered or carry out unnecessary treatments so they can receive a payment. Someone may use another person’s Medicare card to receive treatment they are not entitled to or a company uses false information to persuade you to join their scheme.
In the UK, patients use the system when they are not entitled to claim free treatment, or excessive amounts of money are spent on useless products and services, usually as a result of financial mismanagement.
No Limit on Fraudulent Activity
There is no limit on how many ways healthcare systems can be defrauded, which makes it difficult to put a stop to the fraudulent activity. It takes cooperation from everyone to put a stop to the fraud, but technology has a role to play.
Only a small fraction of fraud is ever detected and only a small amount of the money paid out in fraudulent claims is ever recovered. One of the biggest problems is crunching the data. The average healthcare system generates a huge amount of data every single day, so it is hardly surprising that so many transactions fall through the cracks.
Spotting Suspicious Activity
Large credit card companies use sophisticated data analysis to manage risk and identify fraudulent activity. Real time data is analyzed and if a higher risk than normal is identified, payments are stopped and the transaction is investigated. The same risk analysis and data tracking tools can be used to great effect within healthcare systems, as similar patterns of fraud usually prevail in that a small number of users seek to work the system to their personal advantage.
Technological systems can be used to review large amounts of data to identify suspicious patterns and anomalous activity. Healthcare claims can be reviewed by way of real-time payment tracking applications. If patients are making multiple claims for the same things, data tools will spot the patterns and red flag the transactions. Data analysis can also be used to detect up-coding claims where bills are submitted at higher rates.
Big data analytics are highly effective at predicting where fraudulent activity is taking place. However, although modern technology does an excellent job, it still relies on human beings working within the healthcare system to actually take note of what the data tells them. Unless people manage the data produced by analytical software and act upon it, fraud will continue to run rampant and billions more dollars will be lost to fraudsters.