Telehealth has played an important role in giving patients medical care during COVID-19, but it has also led to growing amounts of valuable medical data — and with a record number of new healthcare fraud cases last year, providers need a plan for prevention. At a time when fraudsters are constantly evolving their schemes to take advantage of the global pandemic, healthcare organizations relying on human FWA detection are bound to let cases slip through the cracks. Here Beth Griffin, VP of Mastercard’s Cyber & Intelligence Healthcare unit discusses the steps providers can take to help mitigate fraud risk.
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Can you give an overview of some of the main issues surrounding healthcare FWA?
Healthcare data breaches were up 25% in 2020 and the related fraud, waste and abuse (FWA) cases increased with the pandemic as well. This can be attributed to a few main reasons. First, medical data is more widespread now than ever before. While the industry has digitized to allow for the easy flow of electronic medical data, this has also created more potential weak spots for bad actors to exploit.
Second, fraudsters are constantly evolving their schemes to reflect the increasing availability of breached medical data on the dark web. This data can be 50 times more valuable than payment card information and can include personal identifiable information that criminals can use to file false claims or conduct ransomware scams. Additionally, overburdened healthcare organizations are not prepared for these types of attacks, especially amid the ongoing COVID-19 pandemic.
Finally, investigators still rely on outdated methods of detecting FWA that can lead to bias, ethical concerns and false positives. Healthcare organizations need to move beyond these rules-based algorithms and instead use innovative technologies like AI to detect and mitigate FWA quickly, efficiently, and accurately.
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How significant is the issue of FWA? What are some of the biggest risks facing healthcare organizations?
The issue of fraud, waste and abuse is estimated by the NHCAA to be a $300 billion problem in the US alone, and healthcare organizations face evolving scams by bad actors. Breached medical records are increasingly available on the dark web and can be 50 times more valuable than payment card information. Criminals use this medical data to file false claims and for phishing and ransomware scams. Increasing cyber attacks and related data breaches negatively impact the patients, members, and brand perception of healthcare organizations.
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What are some of the processes that healthcare organizations should be implementing to help mitigate these risks?
Healthcare organizations can implement artificial intelligence (AI) solutions to detect and mitigate fraud, waste and abuse. When it comes to protecting the organization, AI is a no-brainer. Because historical records of past decisioning or training exist, there is a clear need for the efficiency and accuracy of AI technology.
Healthcare organizations can protect their technology through a few methods. First, they can train employees to mitigate phishing and malware attacks by testing them regularly with fake phishing attacks to increase awareness. They can also implement digital tools to verify the identity of new patients and members during enrollment and prevent bad actors or inappropriate users from accessing these accounts with sensitive data. Finally, organizations can leverage in-house cybersecurity technology to detect and manage gaps in third-party vendor technology, where data breaches often occur.
For example, Mastercard’s AI for Healthcare FWA solution works well from a compliance perspective because it allows precise real-time processing of healthcare claims using a model that has been trained with all the current rules, regulations, and payment policies. The output of the model is scores and rationale at the claim and provider level. The customer can then confidently use these scores and rationales for the creation of new and more efficient workflows (or to further enhance and automate existing ones. The benefit of AI here is faster processing, more consistent response, higher accuracy, and increased efficiency — all of which makes staying compliant an easier task.
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How can technology help improve these processes?
AI can improve FWA processes and profitability in two key ways:
- By identifying incremental savings – FWA can be stopped proactively or recovered by a Special Investigative Unit (SIU)
- By driving operational efficiency — AI can help prioritize alerts so organizations spend time on those that drive savings
For example, with one recent engagement where Mastercard initially focused on one state Medicare Plan, we were able to identify about $18M in potential incremental savings with AI. The Plan was able to validate that a significant amount of the alerts were truly incremental for follow-up. For this sophisticated large payer, AI has the opportunity to drive huge value for the bottom line.
With the running of this one AI model, Mastercard showed operational efficiency by reducing false positives through prioritized results so the provider could focus on the most valuable alerts. The technology’s adaptive learning also stays ahead of bad actors, so time isn’t wasted on maintaining or updating manual, rules-based algorithms.
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In what way is Mastercard supporting organizations to reduce FWA?
Mastercard is providing proven AI technology to the healthcare market for FWA. This AI has been used for close to 20 years within the Mastercard payment network to stop fraudulent card transactions on a prepayment basis in real-time and at significant scale.
Mastercard is leveraging this proven technology, coupling it with Healthcare FWA SMEs and experienced payments and healthcare data scientists, to create robust AI models that are identifying significant incremental FWA, saving health plans millions of dollars and driving substantial operational improvement (given its ability to be used by an SIU post-payment, but to also detect FWA on a pre-payment basis with high accuracy). It’s a game changer.
