How AI is helping to prevent healthcare fraud

Criminals are getting smarter and the healthcare industry is no exception. In 2021 alone, the Department of Justice (DOJ) recovered more than $5.6 billion from civil fraud and false claims cases. This is the DOJ’s biggest haul since 2014, but a drop in the bucket compared to the estimated $380 billion is lost every year to fraud, waste, and abuse.

These numbers add up to higher premiums and out-of-pocket expenses for consumers, as well as reduced benefits or coverage. What’s more, relaxed telehealth mandates put into place during the COVID-19 pandemic, the increased digitization of health, and the emergence of telehealth platforms have made it easier than ever for fraudsters to operate are all contributing to a growing problem. Pressure is mounting on healthcare providers and payers to find solutions to prevent fraud.

What savvy providers are doing to circumvent criminals

Battling fraud isn’t just for healthcare payers – providers play an integral role too. What are the newest tools in a provider’s fraud prevention arsenal? Automated provider education and compliance programs using advanced AI-based technologies. While some health plans and agencies have looked to more traditional fraud detection systems that rely on rules and reports to flag issues with claims or providers, this approach doesn’t always work because healthcare fraud schemes are always changing. This means the reports, filters, and rules that teams may rely on to catch problems won’t always identify the new problems, and new schemes can slip through the cracks until they add up and impact the bottom line.

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