LexisNexis Risk Solutions has released its list of top trends in health care fraud, waste and abuse. These include:
• The rise of organized crime in health care fraud – In recent years, criminals have migrated from illegal drug trafficking to perpetrating fraud schemes against Medicare, Medicaid and private health insurance companies.
• Increased fraud vulnerabilities due to migration to EHRs and ICD-10 – Concerns surrounding medical identity theft and data privacy are increasing as personal health information (PHI) goes electronic.
• Crackdown on improper payments, led by the Centers for Medicare & Medicaid Services (CMS) – In addition to recovering improper payments and reducing payment errors, new provider enrollment rules under the Affordable Care Act (CMS Rule 6028) seek to ensure that providers and suppliers are screened for their risk of committing fraud, waste, and abuse before being allowed to enroll in federal programs.
• The need for better patient information – With general statistics showing that 5-10% of individual contact information provided by commercial carriers is incorrect and 25-30% of individual contact information provided by Medicare is incorrect, it’s no wonder that payers are challenged with HEDIS reporting and providers’ revenue cycles.
• Increased medical identity theft – Consumers’ increased use of online and mobile tools, along with Personal Health Records (PHRs), can open doors to theft and create even greater risk to misuse of information. Medical identity theft and health care fraud are a significant burden on the United States health care system with industry reports showing the annual cost of fraud in the U.S. estimated to be between $60 and $200 billion.
Among the top technology solutions to help health care payers, providers and patients identify and eliminate fraud at the beginning of the health care cycle before care is given, include:
• Social Network Analytics or data analytics
• predictive modeling
• pre-payment claims analytics
• advanced credentialing and identity management systems
“Unfortunately, it’s a reality that fraud is one of the drivers of the rising costs of health care in both the private and public sectors,” said Harry Jordan, vice president of health care for LexisNexis. “Proactively preventing fraud benefits everyone – patients, providers, and payers. It enables the health care community to focus on delivering high quality care, and helps mitigate the increasing costs of that care.”