LexisNexis Risk Solutions

November 23, 2016

While more than 20 million new people have gained health insurance under the Affordable Care Act, the influx of new patients into the health care system has brought the unintended consequences of more fraud. Fraudulent claims are few but extremely costly, with the National Health Care Anti-Fraud Association estimating that losses are in tens of billions of dollars annually.

An abundance of newly insured individuals brings fresh opportunities for fraudsters to steal their identities and game the health care system using false information. The health care industry’s migration to the digital world has also opened doors for fraudsters. Online portals and telemedicine has enabled patients to receive care without being physically present in a provider’s office, making it much tougher to ensure that those who access care and health information are indeed who they claim to be.

Perhaps more disturbing is that it is not just individual identity thieves fleecing the system; fraudulent health care providers are also to blame. Some providers employ sneaky tactics to create confusion around identities and the claims associated with them, even using the identities of deceased individuals to submit fraudulent claims.

Focus on Health Care Risks 

These reasons are why LexisNexis Risk Solutions is making health care identity and provider fraud one of our key topics during International Fraud Awareness Week. Our new Identity Fraud Prevention Playbook is a good starting point, outlining some of the common health care schemes and strategies to prevent them. The LexisNexis Fraud Awareness Week microsite also presents key insights from fraud battles across industries through videos, whitepapers, issue briefs and infographics, which can health care professionals can benefit. It’s all part of our LexisNexis Fraud Defense Network, a cross-industry initiative linking different kinds of organizations with fraud-fighting resources and data.

Some strategies you can learn from these resources include:

  • Which technologies to invest in to combine and use single patient information coming in from multiple sources.
  • How to use analytics to uncover schemes and shady business relationships, and better understand connections between patients, doctors, facilities and other care givers.
  • How to gather data from multiple sources, including an intra-industry contributory database as well as non-claims data from other industries that may shed light on investigations.
  • How to utilize public records data—such as identification data with name, phone number, address and SSN, as well as other “footprint” data, like bankruptcies, deceased files, watch lists and criminal records.

Old ways of fighting fraud which worked well enough before the digital age are no longer viable strategies. We hope you can gain some insights from our resources to protect health care systems by leverage data to its fullest.