Running in the Never-ending Race Against Healthcare Fraud (Strategic Focus)

Content

• Overview
• Catalyst
  • Summary
  • Key Messages
  • In healthcare fraud prevention, public sector leads the charge
  • Retrospective, prospective and real-time solutions should be used in tandem
  • Collaboration between public and private payers is key
  • Table of Contents
  • Table of figures
  • Market Opportunity
  • Detecting healthcare fraud is a never-ending 'Red Queen's race'
  • Both private and public payers are now shining a spotlight on healthcare fraud
  • In an economic recession, payers are unable to pass higher costs onto patients
  • Government led initiatives against fraud impact the private sector as well
  • As providers move to EHRs and ICD-10, opportunities for fraud will likely increase
  • Yet tackling healthcare fraud is still a sensitive subject that is not taken seriously
  • Within a payer organization, fraud is a politically difficult topic to broach
  • Payers do not want to alienate their provider networks
  • While committing healthcare fraud may be a laughing matter, fighting fraud is not
  • Technology Evolution
  • Old and new tools are being used to fight fraud
  • Healthcare fraud detection is slowly moving closer to real time
  • Retrospective analysis of claims data will continue to play a role in catching fraud
  • The use of prospective analysis is growing and the benefits are clear
  • Regional health information organizations may increase collaboration between payers
  • On-demand solutions are the easiest and most cost effective
  • Educating doctors on good billing practices is a must
  • Looking to the future, EHRs will change billing processes and, in turn, fraud detection
  • Customer Impact: Recommendations to Healthcare Payers
  • Be open to increased collaboration with other payers
  • Incorporate patient inquiries as a part of the fraud detection process
  • If financially possible, consider using more than one solution
  • Go to Market: Recommendations to Technology Vendors
  • IT vendors need to start focusing on medical identity solutions as well
  • Vendors must take market education to a new level, the C-level
  • It goes without saying, but technology companies should continue developing new tools
• APPENDIX
  • Abbreviations
  • Methodology
  • Further reading
  • Ask the analyst
  • Datamonitor consulting
  • Disclaimer
• List of Figures
  • Figure 1: The number of stakeholders involved in the claims process makes it vulnerable to fraud
  • Figure 2: Potential for fraud centers around the provider
  • Figure 3: On the surface, claims processing seems to be straightforward
  • Figure 4: A comparison of real-time, prospective and retrospective analysis
  • Figure 5: Claim submission process will be streamlined in the future due to EHRs