Anthem hack opens multiple inroads to healthcare fraud

Data captured by hackers could lead to false billing and medical identity theft, fueling black market for years to come
Tools

"You might have those situations where the billing isn't fraudulent from the doctor's point of view because he actually [provided those services], but the person receiving those services didn't have their own insurance, so they purchased a medical identity through the black market in order to gain the goods and services that they need," Patterson said.

Furthermore, these schemes could prove elusive for fraud investigators as they attempt to keep pace with criminals.

Hard to detect

A lot of the attention surrounding the Anthem hack has been devoted the possibility of financial fraud, but fraud schemes that revolve around medical identity theft are typically harder to detect and can have lasting impacts for patients and insurers. Most payers still rely on a pay-and-chase model to uncover fraud schemes, but given the amount of information that was accessed in the hack, Anthem will need to put more resources toward a proactive approach for fraud identification, Patterson said.

"I wouldn't be surprised if there is an uptick in fraud since there were 80 million records stolen--there is bound to be a certain percentage of fraud committed with those identities," Patterson said. "If that fraud happens to come through Anthem, as the health insurer that is going to pay these fraudulent claims, they are going a to be looking at that pay-and-chase type of model, and it's going to be a little bit harder to remediate fraud."

From a patient standpoint, medical identity theft can have devastating consequences on an individual's plan of care. While financial fraud can be a tremendous headache, a thief that uses stolen medical information to access care can alter that person's medical record, which could lead to the incorrect treatments or set off red flags with the DEA. This kind of fraud could take months or years to recognize, and the fallout could be overwhelming for someone who relies on his or her medical record to renew a professional license or maintain a job based on certain health conditions.

"Those kinds of things will take a while to sort out," Patterson said. "If you lose your job over something like this, it will be a devastating financial loss--but having your personal health information comingled and getting the wrong kind of treatment, that could obviously have some devastating effects on your health."