Mind Boggling Healthcare Fraud Figures Have Insurers Wondering… “How Can The Criminals Be Stopped?”
As far as healthcare fraud goes, March 2022 has been one for the books. Taxpayers, insurance companies and the insured have been on the hook for billions in fraud losses while criminals continue to scam the system.
Without proper claims analysis, healthcare fraud losses will continue to mount. But new artificial intelligence technologies, ones that are becoming widely popular in the banking sector, may be the answer.
Could the following mind-boggling healthcare frauds have been detected and prevented by AI… before payouts were made?
We’ll discuss more in a moment. First, the frightening figures for March…
The Justice Department claims Methodist Le Bonheur orchestrated an $800 million kickback scheme resulting in hundreds of millions of unwarranted insurance claims payouts…
Fort Myers-based Lee Health and Cape Coral Hospital agreed to pay $12.7 million in fines/restitution to resolve allegations it submitted non-covered claims to public healthcare insurers…
A Tennessee physician was convicted in a $50 million billing scheme…
A California physician and patient recruiter was charged in a $36 million Medicare fraud…
A Virginia physician was sentenced for his role in a $1.8 million fraud…
A New York physician pleaded guilty to a $3 million billing scheme…
And 12 physicians from Michigan and Ohio were sentenced for their roles in a $250 million false billings scam.
A majority of healthcare related fraud occurs when providers submit false or unwarranted claims to insurers. These claims, which can be in the thousands per day, are incredibly difficult for claims departments to analyze effectively.
But with the use of Ai, claims teams could detect even the smallest of anomalies, prevent payouts and halt provider frauds much earlier than ever before.
New tools, created by ToolCASE, a Denver-based customized Ai company, have the ability to analyze millions of healthcare related data points, from almost any number of sources. It could alert fraud, billing and claims teams instantly of even the tiniest discrepancies, forecast expected outcomes and discover minute deviations in the data.
Its real-time analytics systems are designed to assist humans in detecting and preventing fraud, on both the provider side and internally, while streamlining the entire workflow system for the insurer.
Already utilized in the banking and financial services industry, ToolCASE is custom developing artificial intelligence that’s industry specific to the healthcare sector. This AI could fit seamlessly into billing, fraud and claims departments allowing for the almost instant detection of fraud, preventing potentially millions of dollars in losses.
Learn more about ToolCASE, HERE
Or, read more on these seven mind-boggling fraud cases, HERE
