How You Can Detect and Protect Against Healthcare Fraud

Healthcare Fraud is in the Billions

Healthcare fraud and phantom billing has been a very salient topic and criminal matter since the pandemic began a year ago. One recent report by the US Department of Justice underscores how serious the problem has become. The DOJ report issued on January 14, 2021, stated that it recovered $2.2 Billion from false claims in FY 2020 of which $1.8 Billion related to Healthcare. These false claims involved medicines, medical device manufacturers, managed care providers, hospitals, pharmacies, hospice organizations, labs and physicians. Essentially, no aspect of the Healthcare industry was untouched by fraud. The Justice Department also reports that tens of millions more were recovered for state Medicaid programs.(1)

What are these Schemes and Scams?

A deeper dive into the Justice Department report reveals that Healthcare fraud impacts major corporations in two ways:

a) They are paying out significant dollars on claims that are fraudulent.

b) When these frauds are investigated and proven, Healthcare companies accountable for fraudulent payments are subject to huge fines.

Here are some examples:

Kickbacks – the largest area for fraud recoveries relates to drug manufacturers that make kickbacks to doctors prescribing certain drugs. Perhaps the most notorious is the OxyContin prescription scheme. Major corporations such as Perdue Pharmaceutical and Practice Fusion were fined millions for inducing prescriptions through kickbacks.(2)

Fraudulent Lab Tests – The Justice Department reports laboratories, pain clinics, doctors and executives who were convicted and levied fines of $41 million solely on fraudulent tests.(3)

Unnecessary Services – This involves billing for services rendered that were either not necessary or never performed. Hospitals, psychiatric institutions and health insurers are all impacted in paying for fraudulent services. The sums are staggering. In one instance a company that provides management and administrative support for psychiatric and behavioral treatment agreed to pay $117 million to resolve alleged violations of the False Claims Act in Pennsylvania in July 2020.(4)

Procurement and Bribery Schemes – In the past year there were numerous judgements with major fines against a) corporations that engaged in criminal bribery to steer contracts, b) cases of fraudulent procurement of medicines and payments to professional staff and equipment; as well as products and services that did not comply with contract specifications.

The corporations involved are highlighted by the Justice Department in its January 12, 2021 report by the Office of Public Affairs. https://www.justice.gov/opa/pr/justice-department-recovers-over-22-billion-false-claims-act-cases-fiscal-year-2020

These are just a few of the many schemes and scams that illustrate not only the importance of vigilance but the absolute necessity of having a system to detect and protect against Healthcare fraud.

How You Can Detect and Protect Against Healthcare Fraud

The optimal solution to identifying Healthcare fraud and initiating action to prevent fraudulent transactions in the first place is the ToolCASE suite of anti-fraud tools.  The ToolCASE transactional AI capability, called RembrandtAi, is the most cutting-edge Artificial Intelligence on the market.  The Installation and implementation of RembrandtAi is nearly instant, and training is quick and seamless.

RembrandtAi features real-time analytics capability, data aggregation from multiple sources and the presentation of data through visualization and alerts. Clients can anticipate and resolve customer queries, accelerate prior authorizations, review claims, manage memberships and billing and deliver quality improvement and maintain regulatory compliance through automated reports and regulatory updates.

Additional benefits include risk and compliance management for insurance companies including internal audit and cybersecurity capabilities. Transaction, balance and intentions trend and pattern analysis are presented in Data Visualization and Alert formats.

The real-time Ai driven anti-fraud breakthrough is finally here for Health Insurance Organizations.  With RembrandtAi you’ll enjoy intuitive and effective “war-room” style fraud combat tools.

(1) US Department of Justice, January 14, 2021
(2) US Department of Justice, January 14, 2021
(3) US Department of Justice, January 14, 2021
(4) US Attorney Eastern District of Pennsylvania, July 10, 2020

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