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Healthcare fraud doesn’t always require someone to break into a system or invent an entirely fictitious identity. Sometimes the information is real.
A recent examination of durable medical equipment fraud by the U.S. Department of Health and Human Services Office of Inspector General illustrates the problem.
According to an OIG official, a successful scheme can be built around three pieces of information: a Medicare-enrolled supplier, a physician’s identity, and a beneficiary number.
Each may be valid. The resulting claim may still be fraudulent.
That distinction should matter not only to government healthcare programs, but to commercial health plans trying to strengthen their own fraud-prevention strategies.
Healthcare payers have become increasingly sophisticated at analyzing claims. Automated systems can verify identities, compare billing patterns, identify anomalies, and flag providers whose activity differs significantly from their peers. Artificial intelligence will make those systems even more capable.
But there is a fundamental limitation. A system can determine that a provider number is valid. It cannot necessarily establish that the provider is operating where the records say it is.
It can confirm that a physician exists. That doesn’t necessarily prove the physician ordered a particular service.
And it can verify that a member is eligible for benefits without proving that the member actually requested or received what was billed.
That’s why fraud prevention increasingly requires layers of independent evidence.
Analytics can identify activity that deserves scrutiny. Member or provider outreach can answer some questions. And when the uncertainty involves the physical operation behind the claim, field verification can provide information the claims system cannot.
Is the provider actually operating at the reported address? Does the location appear capable of providing the services being billed? Is there appropriate signage and normal business activity? Does what exists in the physical world correspond with what the payer sees in its records?
Those aren’t questions every claim requires. That’s the point.
Commercial health plans don’t need to inspect every provider. They need better ways to identify when the information already available isn’t enough, and they need to obtain another source of evidence before questionable payments continue.
Government healthcare programs have spent years building field verification and other program-integrity tools into their fraud-prevention efforts. Commercial health plans have an opportunity to apply the same principle more proactively.
The goal isn’t to replace analytics with people in the field. It’s to use analytics to determine where independent verification can provide information the system doesn’t already know.
To find out more about how NCCI Services is helping companies mitigate these risks, reach out to Christina at Christina@ncciservices.com or email us at CommercialHealthcare@ncciservices.com.
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