Moda Health turns to automated fraud prevention to help protect members
FHP AF: The release points to a study from the Ponemon Institute that indicates 56 percent of patients do not check health records for accuracy. Why do you think that is? Is fraud simply not a primary concern for patients?
Paullin: Ten years ago, none of us thought that our medical identity would be stolen. We didn't think about the ramifications of that. It's something new. We're just not accustomed to protecting that information the same way we've been taught to protect our financial information.
Unfortunately, the product exists because bad people are doing bad things. Luckily, the product is teaching us all to pay attention to what is happening, not only in our financial health, but in our personal health as well, and making sure we're following and keeping track of all that.
FHP AF: In what ways is this going to help you, as a payer, in terms of saving money and preventing those instances of fraud and abuse?
Paullin: Well, we know that fraud exists, and this is protecting our members. One, we want to make sure we are protecting them for their safety. We're really focused on making sure our members are safe all the time, so this is one way we offer that protection.
Two, it helps protect these higher healthcare ecosystems from fraud. It's helping our members so that they aren't stuck with a bill that isn't their responsibility, it's making sure that actual services are rendered, and making sure that everyone is kind of staying true in terms of the care they are getting. But for us, it's about the protection--protecting members' health information, protecting their wallet, and making sure we're taking care of them in a way we should be.
FHP AF: Is part of this decision based on the large fraud cases that have emerged over the last several years? Has it reached a point where you have to protect those kinds of finances?
Paullin: I think it's more about protecting people's health at the end of the day. Does fraud exist? Sure it does, but it's really more about, at the point of care, if the patient showed up at a hospital unconscious and there is something on their health record because of fraudulent activity, that will hurt them or potentially be a fatal decision because their EHR is wrong. It's making sure people get the right care at the right time because their medical record says the right thing.
FHP AF: Do you think more payers will turn to automated fraud detection as a way to prevent fraud and reduce costs?
Paullin: I can't say what other payers will do, but I do think it's important to protect members and patients, so I think people will be looking at all sorts of automated ways to take care of that.
[Editor's Note: This interview has been edited and condensed for clarity.]
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