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Radar On Market Access: Health Insurers Turn to Data Analytics to Combat Fraud, Waste and Abuse

Posted by Barbra Golub on Aug 29, 2019


According to the National Health Care Anti-Fraud Association, health insurers lose more than $10 billion each year to health care fraud, waste and abuse. And according to experts, while strides have been made in combatting fraud, there is always going to be some new product ripe for fraud, along with the targets that have been around for years.

Melissa Jampol, an attorney with Epstein Becker Green and former assistant U.S. attorney, tells AIS Health that "insurers need to stay one step ahead of the trends." She is a big proponent of data analytics, contending that robust analytics help insurers analyze prepayment claims and audit results, trying to prevent fraud before it happens and catch it after the fact.
Jampol says that opioid use and abuse is still a hot issue. Other targets of health care fraud she sees are telemedicine and durable medical equipment.

Jo-Ellen Abou Nader, vice president of fraud, waste, and abuse and supply chain optimization at Prime Therapeutics LLC, says last year the PBM launched a new data analytics platform to help identify and weed out fraud, waste and abuse.

She adds that "fraud is an evolution." While health plans are still seeing the same opioid fraud schemes, there are also new schemes trending due to increased access to technology. For example, technology allows fraudulent companies to have more access to patients who don't have the ability to see a caregiver in person.

Highmark Inc. has also seen a rise in telemedicine schemes involving compounded pain creams. The insurer is combating this type of fraud by identifying large spikes in certain drugs prescribed, says Kurt Spear, vice president of financial investigations and provider review at Highmark. "We can flag those claims, put a stop on them, and do an investigation," he adds.

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Topics: Industry Trends, Provider, Payer