How the Marriage of AI and H.I. Impacts Healthcare Costs

Identifying healthcare fraud, waste and abuse is a highly evolved practice that is best done with a marriage of artificial intelligence (AI) and human intelligence (HI) capabilities. As the losses attributed to fraud continues to grow, unfortunately, we all share the responsibility of paying for it. The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year.1 The payment integrity review process of analyzing a healthcare claim can be strengthened by implementing a hybrid approach of both HI and AI. However, it's important to understand the benefits and limitations of each to avoid pitfalls that can arise. On July 20, 2022, the Department of Justice announced criminal charges against 36 defendants in 13 federal districts across the United States for more than $1.2 billion in alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and durable medical equipment (DME) schemes.