Running in the Never-ending Race Against Healthcare Fraud (Strategic Focus)

Table of Contents

OVERVIEW

• Catalyst
• Summary

KEY MESSAGES

• In healthcare fraud prevention, public sector leads the charge
• Retrospective, prospective and real-time solutions should be used in tandem
• Collaboration between public and private payers is key

MARKET OPPORTUNITY

• Detecting healthcare fraud is a never-ending ‘Red Queen' s race'
• Both private and public payers are now shining a spotlight on healthcare fraud
  • In an economic recession, payers are unable to pass higher costs onto patients
  • Government led initiatives against fraud impact the private sector as well
  • As providers move to EHRs and ICD-10, opportunities for fraud will likely increase

• Yet tackling healthcare fraud is still a sensitive subject that is not taken seriously
  • Within a payer organization, fraud is a politically difficult topic to broach
  • Payers do not want to alienate their provider networks
  • While committing healthcare fraud may be a laughing matter, fighting fraud is not

TECHNOLOGY EVOLUTION

• Old and new tools are being used to fight fraud
• Healthcare fraud detection is slowly moving closer to real time
  • Retrospective analysis of claims data will continue to play a role in catching fraud
  • The use of prospective analysis is growing and the benefits are clear

• Regional health information organizations may increase collaboration between payers
• On-demand solutions are the easiest and most cost effective
• Educating doctors on good billing practices is a must
• Looking to the future, EHRs will change billing processes and, in turn, fraud detection

CUSTOMER IMPACT: RECOMMENDATIONS TO HEALTHCARE PAYERS

• Be open to increased collaboration with other payers
• Incorporate patient inquiries as a part of the fraud detection process
• If financially possible, consider using more than one solution

GO TO MARKET: RECOMMENDATIONS TO TECHNOLOGY VENDORS

• IT vendors need to start focusing on medical identity solutions as well
• Vendors must take market education to a new level, the C-level
• It goes without saying, but technology companies should continue developing new tools

APPENDIX

• Abbreviations
• Methodology
• Further reading
• Ask the analyst
• Datamonitor consulting
• Disclaimer

FIGURES

• Figure: The number of stakeholders involved in the claims process makes it vulnerable to fraud
• Figure: Potential for fraud centers around the provider
• Figure: On the surface, claims processing seems to be straightforward
• Figure: A comparison of real-time, prospective and retrospective analysis
• Figure: Claim submission process will be streamlined in the future due to EHRs