AHIP Provides Five Deep Insights On Future of AI in Healthcare Fraud Detection

$300 billion is wasted on fraud, waste, and abuse charges in healthcare every single year. That’s up to ten percent of American healthcare spending, which in turn represents 18% of U.S. gross domestic product. That’s a big problem, and it’s only increased in the COVID era. 

AHIP (America’s Health Insurance Plans) Institute and Expo is one of the premier conferences for healthcare industry professionals, providing a forum for policymakers, academics, industry experts, and thought leaders to discuss and collaborate on health policy, healthcare operations, and challenges in the field. At the 2021 AHIP Institute and Expo, several experts discussed the benefits and potential for artificial intelligence to help address the growing problem of fraud, waste, and abuse in healthcare today. 

Preventing FWA, Mitigating Losses and Improving Efficiencies with AI

The “Preventing FWA, mitigating losses and improving efficiencies with AI” panel at AHIP 2021 gathered a panel of industry experts to discuss how AI can help address the fraud, waste, and abuse issue in healthcare. The panel included Mastercard’s Beth Griffin, VP for Healthcare Vertical and Tim McBride, Director of Healthcare Product Development and Innovation, Integrity Advantage’s co-founder and VP, Jessica Gay, and Milliman Inc’s Principal, David Cusick. 

They acknowledged that while the fraud, waste, and abuse issue in healthcare is pervasive, not all waste is fraudulent. Complex medical billing and coding protocols do lead to billing errors, and some practitioners may order unneeded procedures out of an abundance of caution. However, the sheer volume of F,W&A charges necessitates leveraging AI technology to address the issue, as human analysts can’t review millions of claims every day for complex fraud, waste, and abuse issues. 

Five key insights were discussed during the panel:

1: Advanced AI Can Detect Criminal Behavior

Public and private healthcare plans are now the leading vehicle to launder dirty money in the U.S., according to the U.S. Treasury Department. Healthcare fraud often flies under the radar but outstrips securities fraud and credit card fraud by significant amounts. The COVID crisis worsened this, with various fraud schemes attempting to exploit the vast sums of money dedicated to combating the pandemic. 

Panelists noted that AI models are currently able to consistently identify healthcare claims fraud, prescription abuse, and other common healthcare F,W&A charges. 

2: Artificial Intelligence Serves As A Force Multiplier

Old-style rules-based F,W&A detection technology doesn’t keep pace with evolving fraud schemes, and existing payment integrity and special investigations unit (SIU) personnel just don’t have the time to keep those rules sets updated and investigate the many claims in the system. Tim McBride from Mastercard pointed out that just updating the rules for those systems can take up 240 human hours over the lifetime of legacy systems. He also discussed the cost of investigating false positives.

AI learns as it goes, in real-time, and flags possible fraud for human intervention. 

3: AI Can Detect Coding and Billing Errors

 Medical billing and coding are infamously complex and get more so every year as technology increases healthcare options and telehealth becomes more prevalent. A $10000 hospital bill has an average of $1300 in billing errors, according to Equifax. A strong AI system can detect these billing errors and flag them for intervention, reducing the percentage of funds wasted on billing errors so those funds can be used to provide better care for plan members.

4: Identifying Waste With AI

Waste frequently falls through the cracks of even strong payment integrity efforts. Some practitioners may be too cautious and order unneeded tests or procedures, and it’s hard to separate these out. But AI excels at pattern recognition, and can call out systemic or localized patterns of potential waste so they can be addressed.

5: AI Streamlines Operations for Higher Efficiency

AI processes and analyzes data at incredibly high speed and with the near-infinite ability to scale. This frees up man-hours for other tasks, increasing efficiency across entire organizations in disparate operational areas. 

Alaffia Health: Putting AI To Work For You

Ready to put AI to work for your organization? You don’t need to build a custom solution from the ground up. Alaffia Health’s AI-driven Payment-Integrity-As-A-Service℠ platform integrates seamlessly with your existing systems for a turnkey payment integrity solution. Our advanced AI scans healthcare claims, focusing on high-cost error-filled inpatient visits. This allows our expert payment integrity and medical billing analysts to focus their efforts on the overpayments that cost your organization the most. 

AI is the future of payment integrity. Partner with a proven payment integrity team and control your costs, and ensure you have the resources to provide stellar care to your plan members. It only takes a few minutes to learn how.  Schedule a chat with us today.