To more effectively identify healthcare providers committing fraud, a national insurer and a multistate payer have announced a plan to pool data with a third-party risk analytics firm.
The players are Humana, Louisville, Ky., which covers more than 12 million people in 50 states, Centene, Clayton, Mo., which primarily provides Medicaid managed-care coverage to 2.6 million people in 19 states, and Verisk Health, a subsidiary of Verisk Analytics, Jersey City, N.J.
“It's time to recognize that no one can be nearly as successful alone as we can be together,” said Centene's Robert Miromonti, vice president for ethics and compliance, in a news release. “This is definitely the case with fraud, waste, and abuse, and that's why we're excited to be members of this innovative initiative. We're confident that a cross-payer, data-driven solution will prove invaluable in the fight against fraud.”
Michael Williams, a spokesman for Washington-based National Healthcare Anti-Fraud Association, said members have been sharing data about known or potential threats for years in an effort to combat fraud schemes that are estimated to cost tens of billions of dollars a year.
Health insurers also have been sharing information about individuals for medical underwriting, and that information can be used for anti-fraud purposes.
What's different about the new collaborative is the sharing of data in which the fraudsters are not yet identified, according to Karthik Balakrishnan, senior vice president of fraud solutions and analytics at Verisk.
Fraudsters are sophisticated enough to estimate how many times they can bill for a certain procedure and not trigger an alert from a specific insurer, Balakrishnan said. “They have cheat sheets. They know what plans have what thresholds to deny claims and they stay a step ahead of that.” But by cross-comparing claims from multiple plans, the software can identify fraudulent behavior, he said.
Property and casualty insurance carriers have been pooling claims data this way for years to find fraudsters, but there are at least two reasons healthcare payers have not, he said. “Some of it has to do with the capabilities and the maturation of the (analytics) capabilities” Balakrishnan said. “But I think the real hurdle was data sharing and privacy and (the Health Insurance Portability and Accountability Act). That can land you in a lot of trouble.”
Verisk has been able to convince Humana and Centene leaders that their data will be kept secure and segregated. “There is no raw data from one health plan that could make its way back to another,” Balakrishnan said.
Follow Joseph Conn on Twitter: @MHJConn
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