To most Americans, the phrase "Medicare Fraud" brings up images of individuals who cheat the system to collect healthcare when they don't need it. While those cases do exist, that's not what really concerns fraud analysts, insurance companies, and government agencies. The strong majority of fraud cases involve healthcare providers. The problem is that there are so many providers that current healthcare solutions aren't advanced enough to identify fraud in the vast amount of information. One example is the problem of prescription billing abuse.
We are bombarded with healthcare mandates aimed at bettering care by eliminating waste and improving health. But these initiatives typically focus on revenue-based penalties that stop payment to providers. They don't get to the root of the problem - patient illness. The RIGHT way to improve the health of individual patients and our communities is to stop illness before it happens. We use advanced artificial intelligence and the latest in Clinical Patient Pod technology to predict events so that providers can stop losses before they happen.
Health insurance is a critical component of the healthcare industry with private health insurance expenditures alone estimated at $1.1 billion in 2016, according to the latest data available from the Centers for Medicare and Medicaid Services. This figure represents 34 percent of the 2016 National Health Expenditure at $3.3 trillion. In this article, we will look at four AI applications that are tackling problems of underutilization and fraud in the insurance industry. Some applications below claim that they are using artificial intelligence to help improve health insurance cost efficiency, while reducing waste of money on underutilized or preventable care. Other applications claim to detect fraudulent claims.
Artificial intelligence applied by health insurers could help save millions of dirhams a year in fraud and abuse within the UAE healthcare system, analysts claim. Swiss software company Netcetera has completed a successful trial of its latest technology within a major health insurer, spotting almost 37,000 suspicious claims made by more than 4,000 doctors between 2016-17. Those bogus claims totalled Dh21 million and would usually have gone unnoticed by insurers, who would end up paying out for unnecessary treatments given by hospitals and clinics. The system developed by Netcetera uses an AI model that runs an algorithm to detect a pattern of behaviour. The AI model built into an insurers claim system will recognise a usual pattern of prescriptions and raise a red flag when a doctor delivers an abnormal course of treatment.