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In fight against fraud, humans just as important as machines


Predictive analytics. Predictive analytics. Predictive analytics.

Say it three times fast. Or, if you're so inclined, say it 100 times at a slow, deliberate pace.

Predictive analytics is the catchphrase of the last several years in healthcare. It assists insurers in identifying gaps in careand it helps hospitals reduce surgical infections. It's the Swiss Army Knife of 21st century tools.

In terms of healthcare fraud, predictive analytics has been crowned the saving grace by pushing the industry from the tired, "pay-and-chase" model of fraud enforcement to a new, cutting-edge approach that uses multiple data sources to prevent payments from hitting a fraudster's bank account. As the threat of medical identity theft grows, IT systems that prevent breaches and identify fraudulent claims after a breach occurs are becoming even more essential.

I think we can all agree we're pretty infatuated with the prospect of predictive analytics. And we should be. Developing programs, algorithms and technology that can do the dirty work of spotting unusual billing practices amid a virtual stack of millions upon millions of claims is exciting and important in a number of ways. But that unbridled excitement shouldn't distract from a balanced approach to fighting fraud--the kind that includes a few warm bodies to accompany those faceless machines.

Last week's survey released by the Medical Identity Fraud Alliance (MIFA) is a brief but important reminder that payers and providers alike-- and particularly the executives who have budgetary input--should ensure that their fraud prevention expenditures reflect that balanced approach. Although the survey indicates that spending on medical identity fraud prevention and mitigation is trending up, the majority of that money is going toward IT systems that detect, prevent and mitigate fraud.

That statistic, in and of itself, is not necessarily a sign of trouble. As medical identity theft has become a top priority for many healthcare organizations, thanks to a number of breaches that exposed the personal health information (PHI) of millions, IT programs are a key cog in providing more robust protection. Unfortunately, those systems are also very expensive, and take time and manpower to implement. Remember, the Centers for Medicare and Medicaid's (CMS) Fraud Prevention System (FPS) cost $77 million to implement and infamously churned out just one bad claim totaling $7,591 within the first several months.  

However, 72 percent of respondents in the MIFA survey ranked personnel as their first or second priority in preventing medical identity theft and fraud. That tells you one thing: Healthcare organizations want more people devoted to medical identity theft and fraud prevention, but most of their budget is still going toward IT systems.

"Technology is a means to an end, but it's not the end," Ann Patterson, senior vice president and program director at MIFA, told me when I asked her about this divide between humans and technology.

"Technology will not be able to conduct a fraud investigation--the data it collects, analyzes and presents can facilitate an investigation, but it cannot actually conduct the investigation," she added. "There are no robots or computers in the field conducting interviews or testifying in court against identity thieves. Ultimately, it's vitally important for healthcare organizations to invest in their human capital to fully leverage their technology."

I agree. Technology, although powerful, needs a human navigator (or multiple navigators, in some cases), particularly someone with valuable expertise in current fraud trends who knows what to look for in the wake of a data breach. The data that emerges from IT systems is only useful when someone can see and act on that information. Otherwise, it's really just a lot of money spent on wires, plugs and microchips.

"Technology without the human element to interact with it is leaving something on the table," Patterson added.

The threat of medical identity theft is not going away. If anything, it's gaining traction as a conduit to fraud. The prospect of predictive analytics and other data-mining software is certainly worth getting excited about, but as we continue navigating this escalating threat, let's not overlook the importance of involving living, breathing, critically thinking fraud experts in that process. - Evan (@HealthPayer)