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If Americans thought health care was expensive before the pandemic, they — and their wallets — are about to be hit with a harsh reality: Patient care costs are expected to increase 6.5% this year, slightly more than before the pandemic , according to The PwC Health Research Institute. What should be even more troubling is that a significant portion of what the United States spends on health care annually is lost to fraud, waste, and abuse.

The most egregious cases of fraud and abuse are infrequent, but they have an impact—and sting all those striving to make health care safer and more accessible. Take, for example, the case of an oncologist who prescribes chemotherapy to patients without a cancer diagnosis. Or the cardiologist who does unnecessary stent surgeries. These are real-life cases of fraud that artificial intelligence (AI) technology is uncovering for healthcare payers. Although basic errors in medical coding and updating Covid care are much more common, the grim reality is that in 2021 alone, the Department of Justice (DOJ) recovered more than $5 billion from civil fraud and false claims cases, just a small fraction of the estimated $380 billion lost each year. That’s a staggering number, and it’s only increasing.

Five key problem areas

Executive payer leaders in healthcare recently gathered in a virtual roundtable to find out how the pandemic has changed their views on medical costs, telehealth, virtual care and technology investments related to fraud, waste and abuse.

Here are the valuable takeaways from their discussion:

  1. Many factors contribute to rising health care costs, but the main drivers are Covid testing and treatment and staff shortages.
  2. While overall healthcare utilization is still down by about 3-4%, utilization in lab work increased dramatically by 15%. Increasing laboratory work should be monitored by healthcare providers because it leads to an abundance of fraud.
  3. Covid care and treatment services are being over-coded, such as ordering respiratory panels or charging for full patient assessments when only a Covid test is required. For example, in May 2021, the US Department of Justice announced criminal charges against 14 defendants in the United States who profited from the Covid pandemic and resulted in more than $143 million in fake accounts.
  4. Staff shortages during Covid have also affected access to carewhich creates a backlog that is expected to last at least two to three years.
  5. As the use of telehealth increases, it is vital to evaluation monitoring and management (E&M) upcodingwhere providers claim to provide a higher level of service than is provided or even claim to offer services that are simply not possible unless the patient has been physically examined by the physician.

How technology can be part of the solution

Adoption of AI, machine learning (ML) and automation to monitor fraud, waste and abuse in healthcare is growing. Healthcare payers, agencies and pharmacy benefit management organizations are realizing the value proposition of these technologies as they provide transparency across the payment spectrum and create a unified view of claims, providers and patients to proactively limit integrity costs.

Here are some of the ways healthcare payer executives are maximizing technology in their day-to-day operations:

  • AI and ML help tackle complex problems like getting billing accurately, auditing code, and finding complex areas that historically relied on manual discovery. This is a big win in the existing staffing shortage.
  • AI’s potential for early detection and automation is another reason to invest – especially when it comes to fraud related to Covid care and treatment.
  • AI and other technologies can create a more cohesive and holistic approach, enabling organizations to better communicate the value of payment integrity programs to suppliers and customers.

Catching those responsible for fraud, waste, abuse and error is an act of social good. As we chart a new course in this post-pandemic era, healthcare leaders who are joining forces to explore the power of AI, ML and automation are directly helping to overcome the barriers that have held us back for too long. When we embrace innovation together, we can transform healthcare to deliver more effective and affordable care for all.

Photo: adventtr, Getty Images

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