Why medical health insurance fraud is dangerous for everybody

Some might consider medical health insurance fraud as a victimless crime, however it’s hitting Americans the place it hurts: their wallets and their high quality of care.

That is in keeping with Karen Weintraub (pictured), president of Healthcare Fraud Shield.

“If you look online, especially from government reporting from Medicare and Medicaid, [health insurance fraud] is over $100 billion, but if you start to incorporate commercial data, you’re probably looking at way over $200 billion in potential fraud, waste and abuse,” Weintraub stated.

Bad actors concerned in medical health insurance fraud might use the proceeds to splurge on greater homes, planes and different luxuries. Meanwhile, their fraudulent positive factors translate to “greater premiums for other people”, Weintraub stated.

Health insurance coverage fraud can even put affected person high quality of care in jeopardy.

“They’re treating a patient for something that they don’t need, and can actually be harming them,” Weintraub stated. “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 and causing a whole host of problems.”

In 2015, Detroit-area MD Fata was sentenced to 45 years in jail for his function in a healthcare fraud scheme that included administering medically pointless infusions or injections to 553 particular person sufferers and submitting to Medicare and personal insurance coverage corporations to the tune of $34 million in fraudulent claims.

In an interview with Insurance Business, Weintraub spoke about how the adoption and use of AI can contribute to medical health insurance fraud and, conversely, how this expertise can even remedy the historic drawback of detecting fraud, waste and abuse if carried out accurately.

How suppliers can use AI to commit medical health insurance fraud

AI hype has labeled it a transformative device that may streamline and increase an organization’s inside and exterior operations, nevertheless it may additionally function an insurance coverage fraudster’s ally.

“From a provider perspective, I see more [use of AI] – they’re potentially using AI to generate medical records, which makes it more of a challenge for those of us who analyze data and review medical records to determine whether services are appropriate,” Weintraub stated. “Now we are looking at AI to detect AI.”

One of the principle issues with adopting AI or different generative language fashions like ChatGPT is the necessity for extra scrutiny in the direction of information hygiene and ensuring the data that’s inputted and extracted from these applied sciences is right.

“Generative AI would be what providers are using to generate content in their medical records – there’s pros and cons to that it can certainly be a time saver, but it’s yet to be proven to be fully accurate,” Weintraub stated. “Not only is it generating records that may or may not represent actual services that are rendered, but it may be completely fabricating things, resulting in what is called ‘hallucinations.’”

How AI can be utilized as a device to catch medical health insurance fraud

AI poses a menace and a problem, nevertheless it additionally gives potential advantages.

“I’ve seen a lot of healthcare vendors come and go,” Weintraub stated. “Analytics is great technology but really having a deep understanding of the complexities and the nuances of healthcare varies by payer, state, line of business, and product type such as Medicare versus Medicaid versus commercial, and within commercial plans, there’s so many different variations and coverages, there’s no consistency.”

AI that has the power to take these information nuances and analyze it at a a lot bigger scale is how AI may show very useful by taking all these complexities and determining issues that the human eye wouldn’t essentially have the ability to pinpoint.

“The human eye can look at the output of the AI, and know whether that makes sense or not,” Weintraub stated. “If the data is not right, then the AI output isn’t not right – you’ve got to know that, and if some clients have unclean data, that’s going to impact the results of any analytics, not just AI.”

Weintraub is optimistic that AI can nonetheless be an enormous assist whether it is approached with warning and scrutiny.

“With the use of our own AI to help detect data nuances and potential fraud, we found things that our traditional targeted analytics haven’t identified, Weintraub said. “It can definitely find pockets of things that are emerging, or things that we’re just not aware of,” she added.

Weintraub has more and more seen completely different corporations develop AI governance committees to verify information is used ethically, responsibly and appropriately.

“I think you’re going to start to see a little bit more scrutiny, not just within payer organizations and insurance companies, but within the vendors that they use as well,” she stated.

Do you suppose AI can be utilized to assist medical health insurance fraud? Sound off within the feedback.