Stopping Healthcare Fraud Before It Can Start

In response to a reporter’s question, notorious bank robber Willie Sutton was quoted as saying thieves rob banks “because that’s where the money is”. Today, the money is in a wide variety of areas beyond banks, including the enormous – and growing – healthcare business. As a result, the amount of theft in the healthcare industry is enough to give any honest person a headache. The FBI estimates that healthcare fraud is an $80 billion annual challenge.

With so much at stake, healthcare providers and insurance companies need new methods and tools for preventing phantom billing and other forms of fraud. At the same time, providers are looking for better ways to protect their patients’ medical identity, which has become critical. A recent report by IBM found that one in three patients had their healthcare data stolen or hacked in 2015. Additionally, the largest provider clearing house in the U.S., which processes six billion claims per year, estimates that phantom billing accounts for nearly 40 percent of all healthcare fraud.

To combat phantom billing, medical identity theft and other forms of insurance fraud, payers and providers often turn to big data analytics to identify irregularities. The drawback to this approach is that analytics are only applied after a claim has been submitted and paid – long after the fraud has occurred and too late to prevent it. Additionally, data analytics are incapable of capturing fraudulent billing for services not rendered when a patient is not physically present; as such claims may appear to be correctly coded and will likely be paid by the insurance provider. In both cases, the only recourse payers have is to attempt to recoup payments, which in most cases is difficult if not impossible.

Preventative measures are vital for detecting and preventing fraud before services are provided, payments are made, money is lost and medical records are corrupted with misinformation. The key to accomplishing this is to make sure patients are properly identified and confirm they have appropriate insurance coverage at the provider’s office – before the fraudulent billing can occur.

Identity confirmation is traditionally performed using ID cards (things you have) or biographic information (things you know), both of which can easily be lost, loaned or stolen by determined identity thieves. The third category – things you are, or biometrics – is the most accurate identity verification method for protecting patients from identity theft, thereby ensuring accurate entries in patient records and preventing phantom billing. Common biometric identifiers include fingerprints, voice pattern and irises, all of which are unique to each individual and cannot be lost, stolen or otherwise fraudulently used. When included as part of the claim submission process, records created using biometric information confirm patients’ identity and whether they were present or absent at a provider’s facility. This has the potential to significantly reduce the insurance and medical identity fraud that costs providers and payers dearly each year.

While all biometric identifiers are substantially more accurate than traditional identification methods, fingerprints, voices, facial characteristics and others can change over time naturally as an individual ages or as the result of injury or cosmetic surgery. To compensate for these potential changes requires patients to be periodically re-enrolled in the system to ensure most the most accurate information is available for identification. However, this necessary inconvenience can impact both staff productivity and a provider’s ability to properly identify patients.

Another downside of many biometric identifiers, particularly fingerprint and hand recognition, is that patients must make physical contact with a surface that has been touched by others. Because very few people visit a healthcare provider when they are feeling well, this contact presents significant hygiene issues that can have disastrous results. Finally, there can be issues with false acceptance or rejection, which varies depending on the accuracy of the biometric sensor being used.

Iris recognition, on the other hand, is the most convenient, accurate, reliable and hygienic of the many biometric identifiers. Iris patterns normally remain nearly unchanged over most of a person’s lifetime, and recognition can be accomplished quickly and easily without requiring contact with a potentially unsanitary surface. Adding to the power of iris recognition are computing platforms and new mobile technologies that deliver the convenience of identity verification on easy-to-use devices such as tablet computers that providers already use and with which they are familiar and comfortable. With a mobile biometric solution, each patient’s iris pattern becomes a unique key that unlocks access to his or her personal electronic medical record (EMR), ensuring the correct record is opened every time within seconds.

These solutions also make it impossible for someone to pose as a friend, family member or other individual to take advantage of insurance benefits. When performed at the front desk or reception window in a provider’s office, this also protects patients from unknowingly falling victim to medical identity theft.

Enrolling patients in the system for verification is easy and can be accomplished with a simple photo taken by an iris camera built into or connected to a tablet computer. These technologies provide the real-time data critical to proactively combatting phantom billing and identity fraud by accurately ensuring patients are who they claim to be. Insurance payers also receive instant confirmation of patients’ identity, as well as the time and location information of office visits. Providers benefit from the ability to provide accurate, enhanced patient care while proactively mitigating healthcare fraud with a single device. Streamlined billing processes translate into lower staffing costs and shorter payment windows for services provided, only increasing the value of these solutions.

When fraud is detected after insurance payments have been issued, it’s much too late to address it. Accurately and proactively identifying patients in a provider’s office before healthcare services are performed significantly reduces the likelihood of phantom billing and medical identity theft – and the overwhelming financial implications of each. An added benefit is the ability for providers to provide quality patient care by ensuring patients’ medical records are accurate and free of misinformation. There are many methods for confirming individuals’ identities, but only highly accurate biometrics such as iris recognition offer the high level of accuracy, convenience and hygiene to help providers and insurers keep healthcare fraud from taking an annual $80 billion toll on our medical and insurance systems.


Photo courtesy of: Security Info Watch

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