Finance, Financial Services, Fraud Detection, Telehealth

Healthcare Insurance: Looking Back at 2020

Rachel Robison

In 2020, society witnessed the COVID-19 pandemic and the massive growth in virtual medical care, or telehealth, fueled by the swift onset of social distancing and quarantines.

Since March, the Centers for Medicare & Medicaid Services has approved dozens of new billing codes which have allowed healthcare professionals to administer telemedicine (e.g. telephone, video and email services) and bill for these digital services. There are clear benefits for telehealth patients as it continues to go mainstream. For example, someone who is experiencing flu-like symptoms, no longer has to leave their home, sit in an over-crowded waiting room in order to obtain an antibiotic prescription, and then go pick it up from the pharmacy, before finally returning home to rest.

 

From a business perspective, this surge in telehealth has also paved a path for fraudsters to take advantage of health insurance. Based on a survey by Sage Growth Partner (SGP) and Black Book Market Research, telehealth visits have increased from 25% to 59%. A 34% increase in the first six months of the pandemic has opened the door for cyber risk.

 

History illustrates a common sequence of chaos or crises occurring, and like clockwork, trickery or fraud is just around the corner. Take the 1918 influenza pandemic for example, in this case, Charles Ponzi and his “ponzi” schemes commenced in the ripple effect. A recent example of this pattern was evident with the Great Recession, where investment fraud and consumer scams ran rampant following the 2008 financial crisis. Today, the adsorbent and unprecedented influx of telehealth insurance fraud, born of 2020’s pandemic chaos, continues to highlight opportunities made available for savvy fraudsters.

 

This past fall,  the Department of Justice (DOC) reported that 75% of recent health care fraud losses are attributable to “telemedicine fraud cases.” With more than $4.5 billion in losses tied to telehealth, it is imperative for you to assess your business and take action to protect it from fraudsters.

 

So what exactly do telehealth fraud schemes look like?

  • Billing medically unnecessary services
  • Billing for services that are not provided to the patient
  • Submission of claims for services for ‘phantom’ patients
  • Billing virtual check-ins or e-visits as telehealth visits with a higher reimbursement rate
  • Up-coding: inflating the time and complexity associated with office visits to increase reimbursement
  • Unbundling: billing global or grouped procedures as separate claims to increase reimbursement
  • Illegal kickbacks: payments of kickbacks in exchange for a physician prescribing or ordering durable medical equipment and diagnostic tests

 

The FBI has stated that it “…and its partners are working tirelessly every day to detect and combat health care schemes,” but what if there was a more efficient method to eliminate and prevent telehealth fraud?

 

NEMESIS gives businesses the power to wield the tools necessary to outsmart fraudsters and avoid their swindling schemes before negatively affecting their bottom lines.

 

How is NEMESIS best equipped to detect telehealth fraud?

  • Business analysts, with no prior data science background, are empowered to independently work with NEMESIS and its built-in features to monitor and detect abnormal activities in claims and billing.
  • NEMESIS automatically establishes a baseline, or expected behavior, to then determine unexplainable deviations and identify the root-cause in real-time.
  • NEMESIS also conducts fraud scheme auditing – where common attributes among suspicious claims from suspected fraudsters are collected into a detailed report and a hands-on investigation is launched, preventing any potential snowballing schemes.

 

What is NEMESIS’s unique combination of tools to eliminate and prevent telehealth fraud?

  • Intelligent Data Orchestration (IDO)
  • Model Builder & Inspector
  • Insight Dashboard
  • Integrated Case Management (ICM)
  • Machine Learning & AI Technologies

 

If you’re in the market for a one-stop fraud, waste and abuse solution, NEMESIS is the ideal AI-powered anomaly “detective” for the job.

Rachel Robison

Featured Resources

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