Study Shows Huge Opportunities for AI to Fight Healthcare and COVID Fraud

Fraud, waste, and abuse costs are a huge drain on the healthcare system and especially healthcare payers. Payers spend an estimated $300 billion each year on F,W&A costs, and recent trends show that number will continue to rise because of COVID fraud and other factors. 

Healthcare claims are complicated and often need reams of supporting documentation to confirm their accuracy. Compounding the challenge, about 80% of healthcare claims contain at least one error. Payment integrity analysts can only review so many claims, which means many F,W&A costs simply fall through the cracks. 

Artificial intelligence is a cluster of emerging technologies such as natural language processing, machine learning, and optical character recognition that can complete tasks previously requiring human intelligence. AI can serve as a technological force multiplier, allowing personnel to be more efficient and productive. AI has been adapted for a variety of uses across many industries, including healthcare. However, AI adoption has been slow for AI in the medical payment integrity field.  

AI: A Powerful Tool Against COVID Fraud & Other F,W&A Costs

A recent study by showed that only 11 percent of firms currently use AI for individual claim editing, waste, and abuse detection, and only 1 to 2 percent of firms are using them for individual claim fraud detection. The study surveyed 100 healthcare sector executives in the areas of fraud detection, financial planning, risk management, and claims payments, 

Most healthcare firms surveyed in the study use rules-based algorithms, with only 12 percent using true AI technology to detect and address F,W&A. However, larger organizations are more likely to use AI in their payment integrity efforts; 44 percent of respondents that generate over $1 billion in revenue use AI for payment integrity and F,W&A detection, and 36% of organizations between $500 million and $1 billion in revenue.

Those large organizations commonly cite reduction of false positives as their most important benefit. That’s no surprise; artificial intelligence can scan claims for anomalies far faster than a human, but it takes a trained human payment integrity analyst to confirm F,W&A charges. AI excels as a force multiplier in this role, however. Payment integrity analysts can focus on claims most likely to contain COVID fraud or other types of F,W&A costs, meaning more of those charges get caught before an overpayment is made. 

Scaling AI: Finding A Proven Partner

Most of the organizations using AI for COVID fraud and other F,W&A detection and prevention are larger organizations who developed their systems in-house. That’s no coincidence; AI technology is expensive to develop. Machine learning ‌requires vast data sets in order for the technology to teach itself how to recognize F,W&A indicators. Organizations with under $500 million in revenue that have made use of AI in their payment integrity efforts have largely done so by partnering with organizations like Alaffia Health. 

68 percent of survey respondents believe that higher data management costs are the biggest challenge in implementing AI as part of their payment integrity strategy, which is another reason why smaller organizations haven’t developed their own AI-driven payment integrity solutions. It simply makes more sense to partner with an established and proven organization that’s already developed an AI platform ready to deploy at any needed scale. 

Alaffia Health’s solution uses an advanced AI platform to identify high-cost claims most likely to contain errors so that their team of registered nurses, coders, and medical billing experts can review more claims and find more savings for your organization. The result? Reviews that are 5x faster than the industry standard, with a 22% higher average savings over industry discount rates. 

Our solution works. And we put our money where our mouth is, with a contingency-based fee structure that means we only get paid for results. That means organizations with limited resources get access to the same game-changing technology relied upon by the big guys, without breaking their budgets. 

With Alaffia Health on your side, your payment integrity program will be on the cutting edge, delivering lower costs for your members and more stable margins for your bottom line. It only takes a few minutes to learn how to supercharge your payment integrity efforts. Partner with us today.