An Apple a Day Keeps the Fraudsters Away

This is the third blog post in a three-part series on smarter counter fraud. You can read part one and two here.

A quick Google search of the term “healthcare fraud examples” promptly produces a robust list of IRS investigations and public records documenting medical malpractice and deception. For instance, a Louisiana woman submitted false reimbursement claims to Medicare for services that she had actually not administered. She was ordered to pay more than $1.2 million in restitutions.

Unfortunately, not all thefts are detected and caught. Practitioners and individuals from across the country commit scores of tax evasion schemes and fraudulent white-collar crimes daily. IBM reports that the US healthcare industry is losing roughly $180 billion per year due to fraud.

Though these numbers are distressing, experts report that healthcare fraud is on the rise. Experts estimate that fraudulent claims are increasing almost 50 percent annually in the medical field. Advances in technology also enable deception schemes to be more sophisticated and perpetrators to easily slip through the cracks unnoticed.

Healthcare organizations need a comprehensive strategy to detect and prevent these criminals from committing fraud and receiving improper payments. The IBM Counter-Fraud Management for Healthcare is designed to help organizations inhibit new cases while building a stalwart defense system against fraud.

According to IBM, “this adaptable IBM solution looks at the entire lifecycle of counter-fraud operations using tightly woven capabilities including big data and entity analytics to eliminate information silos, expand the observation spaces, and enable unified enterprise business intelligence.” The solution integrates advanced analytics throughout all businesses process to ensure a holistic approach to counter-fraud.

IBM identifies the four critical steps to its fraud prevention strategy: detect, respond, investigate and discover.

• Detect: Determine if a claim, request or document is potentially fraudulent with near real-time analytical fraud models. Use intelligence from past cases to discover fraudulent activity patterns and flag them for future investigation.
• Respond: Process legitimate claims confidently while buffering suspicious transactions. Automate lower risk activity and focus on high-risk transactions with capabilities designed to prevent fraud.
• Discover: Monitor fraud in a business or public organizations by retrospectively reviewing historical data, analyzing patterns and building watch lists to identify individuals or organizations that might be conducting fraudulent activities.
• Investigate: Manage, assign and process fraud cases. Take immediate action to ensure productive and comprehensive investigations. Use the compiled evidence for the thorough analysis needed to build compelling cases for prosecution, recovery or denial of payment.

Attacking fraud from these four angles provides a 360-degree approach to counter-fraud at your healthcare organization. IBM’s service provides all four components in a single solution for the entire enterprise.

“Using the IBM Counter-Fraud Management solution,” says IBM, “helps forward-thinking healthcare organizations proactively combat fraud, strengthen their brand, and deliver shareholder value.”

IBM’s comprehensive counter-fraud solution brings myriad benefits to your healthcare organization:

• Identify fraud before improper payments occur
• Reduce the volume of false positive fraudulent claims
• Quickly distinguish fraudsters from your valued providers
• Improve the effectiveness and efficiency of investigators
• Focus investigations on high-risk cases
• Deter suspicious transactions with confidence
• Avoid financial losses
• Protect your brand reputation
• Meet regulatory compliance obligations
• Employ enterprise intelligence to continuously adjust operations and stay ahead of trends.

Take your organization from ineffective retroaction to forward-thinking prevention with IBM’s Counter-Fraud Management for Healthcare solution. With IBM, your healthcare organization can save valuable money and resources, increase efficiency, and avoid falling victim to the white-collar criminals headlining scandalous IRS investigations.

For more information on IBM and counter-fraud strategies, click here.

The IBM Analytics Solution Center (ASC) is part of a network of global analytics centers that provides clients with the analytics expertise to help them solve their toughest business problems. Check out their Analytics to Outcomes group on GovLoop.