SMARTER STRATEGIES

A Script for Health Care Fraud Solutions

Dennis McCafferty | Date: 03-08-10 | Comments

Whether filing false medical claims or "doctor shopping," the cost of defrauding the health care system runs into the billions. Here are solutions that are stopping cheats in their tracks.

For all the debate over the price of affordable health care, those who cheat the system cost companies billions of dollars a year. Insurance-related health care fraud, waste and abuse alone, for example, are estimated to amount to $45 billion to $150 billion every year. Only 10 cents of every dollar lost to health care fraud is recovered using traditional methods, according to another industry finding. But the IT industry is constantly seeking to provide solutions to help industry officials avoid these losses. Here are four of them:
- Highmark, a Blue Cross and Blue Shield company that covers 25 million people in Pennsylvania, is among the insurers that has benefited from SAS Business Analytics, from Cary, N.C.-based SAS. The solution tracks suspicious behaviors, such as a pattern of making the same claim over time through multiple health care providers. It takes this information to come up with a "fraud score" that helps those overseeing health, pharmaceutical and medical-equipment claims determine whether an investigation is needed. Able to analyze all activities and relationships among patients, providers, suppliers and services, the SAS solution can prioritize risk status for insurers, and provide an alert when suspicious activity surfaces. As investigations are undertaken, it can store interview notes and evidence needed for criminal and/or civil action/restitution, and can even quantify losses.
- For as long as there has been a pharmaceutical system, there have been patients seeking to "doctor shop," i.e., overload on highly addictive but legal drugs by getting prescriptions from several providers at a time. Traditionally, doctors who were suspicious of a patient could only cross-check within their own medical plan�s system. But a product called eScriptMessenger from Hillsboro, Ore.-based Kryptiq is expanding physicians� abilities by connecting them to retail pharmacy networks through what�s called the Pharmacy Health Information Exchange. More than 90 percent of U.S. retail pharmacies use software enabled to connect to this network. Ultimately, it allows doctors to see a complete list of nearly all patient prescriptions, and who�s prescribing them. In Plano, Texas, Dr. Matt Weyenberg has identified at least one patient a week who is abusing drugs by obtaining prescriptions through more than one doctor. Recently, he discovered a new patient was receiving Ritalin from 16 different doctors�something the patient�s own psychiatrist didn�t know about.
- Also: Westerville, Ohio-based Progressive Medical�s IFX 8.0 is an Internet-based claims administration technology platform that detects suspicious prescription-based activity, such as having too many prescriptions being filled out by one party (or a claim having a history that�s considered too long for the type of drug in question, such as a narcotic). A value-added service for Progressive Medical clients, IFX can be integrated with a company�s existing technology, and offers real-time reporting to allow for prompt detection and intervention.
- Counterfeit drugs are also a problem for health care providers and their patients. So a Southborough, Mass.-based company named Covectra is providing solution tools and services to allow manufacturers of drugs to track and authenticate their products throughout the entire factory-to-customer process�from the point of creation/distribution to wholesale to retail to patient delivery. It allows the manufacturers as well as law enforcement authorities and other product inspectors to not only red-flag counterfeit products, but get a sense of how exactly they entered the supply chain. Through a software tool called AuthentiTrack, Covectra cross-references both covert and overt security features printed on the products and packaging materials, from simple labels to cartons with proprietary taggants to Web-based serialization markers. Via smartphones, patients can also check on the authenticity of the medicine by taking a photo of the barcode and submitting it to AuthentiTrack via the cellular network.