The healthcare industry has undergone major transformations over the past few years and has adopted numerous new techniques – remote patient care, online health records, and data-driven care, to name a few.
While these changes have increased the industry’s efficiency, they have also given rise to a new set of problems that include theft of patients’ data. Healthcare agencies are tasked with protecting the patients’ details and medical information. For such agencies, data becomes their best friend. Data can help them address security and fraud prevention. Not only this, it can help them anticipate and address these issues.
Big data analysis is far more efficient than the traditional methods used for the prevention of fraud, waste, and abuse. Some of its benefits are:
- Can process a large volume of historical data using complex algorithms.
- Business process automation can run real-time analysis before proceeding to the next step.
- The analysis is based on both enterprise and unstructured information from the Internet.
- Service is available online as a web-service which does not mandate software installation on the client premise – Pay as you use .
- Big data analysis software undergoes continuous self-learning on the basis of transactions made on an ongoing basis.
Data-analytics, or big data, is increasingly becoming the health care industry’s weapon of choice against frauds. Here’s how big data can prevent healthcare frauds-
Data Defers prescription drug abuse
According to the Centre for Disease Control and Prevention (CDC) prescription drug abuse costs the US government $55 billion annually. In fact, almost half the overdose deaths are related to pharmaceuticals.
The history of a patient will help the doctors and pharmacies prescribe proper medicines and also detect signs of prescription drug abuse.
Complex billing system
In the healthcare industry, the payment is determined by complex codes that identify treatments and procedures. The current coding version, IDN-10, introduced in 2014, contains 67000 diagnosis codes and 87000 procedure codes.
This astonishing number of codes increases the probability of errors by multiple numbers, by the staff that might result in an overpayment. However, the error is not always unintentional.
In July 2017, there was a medical fraud takedown worth $1.3 billion that saw the involvement of over 400 doctors, nurses, and pharmacists. It was a case of an organized fraud cycle where the fraudsters billed Medicare, Medicaid, and other health insurance programs for unnecessary drugs that were not purchased or given to the patients.
Using data analytics will drastically reduce the possibility of error in the coding- intentional, or otherwise, and thus, protect the customers from overpayment.
Provides a great depth of data
For healthcare groups who have invested in big data analysis companies, the process of preventing fraud, waste and abuse have been simplified to a great extent. However, owing to the sheer magnanimity of the information available, the process of sorting through all the information that is available to the insurers is no simple task.
There are huge amounts of data that you need to go through to figure out the details available to insures. On top of that, most of this information comes from disparate sources. There are millions of insurance records. Many of these available records have almost three hundred attributes. It is a deep ocean of data.
In this scenario, big data analysis comes to use extensively. Using data analysis, you can look into the depths of the available information, across various attributes and dimensions of the claims, and determine patterns. When compared against the previously established benchmarks, you will be able to flag claims that are different than the norms and will require you to evaluate deeper into their nature.
Healthcare fraud prevention has saved the industry tons of money
Approximately $4.1 billion stolen or otherwise improperly obtained from federal health care programs was recovered and returned to the Medicare Trust Funds, the Treasury and others in 2011 as reported by the CDC.
Health insurance fraud costs the industry an estimated $70 billion to $260 billion in the US and $30 billion to $100 billion in the EU each year. Historical fraud detection methods only uncover about 10 percent of losses, and because of the post-payment nature of such methods and the resulting pay-and-chase recovery process, less than 5 percent of losses detected are ever recovered. Advanced Big Data platform aids a smooth process and prevents these frauds ultimately saving millions lost every year.
It’s time!
In a nutshell, the healthcare industry is exposed to frauds and malpractices now more than ever. This reduces the available funds for legitimate claims and fosters the fraudsters with more-than-required. But the availability of big data technologies at the forefront of the Health care efforts can help us recreate a world with Zero FWA’!
