Forward-thinking fraud, waste and abuse vendors adopt service-based approach
This is especially true for payers planning an acquisition, Loshe said. "It's much less expensive to take care of potential threats before you've integrated them into your network and before you've paid out a lot of money in claims. Recovery is expensive, time-consuming and ultimately not very remunerative."
Although Lohse said there are probably three dozen vendors in the fraud, waste and abuse marketplace that offer a variety of software and services for both large and small payers, the six companies identified in the report stand out because of their substantial growth and willingness to adopt a service-based approach.
The vendors focus on growing markets, offer an interesting value proposition and show they can master core components of these service-based offerings, he said. "How do you really capitalize on technology that serves your clients from afar? Using software as a service, how do you do so using services that are outsourced from an offshore and onshore basis? [These are] the firms that are showing real distinctiveness in the way they go to market and the services they are offering."
Privacy, security could have trickle-down fraud implications
In the wake of the Anthem hack, the question for healthcare organizations is not if a hack will occur, but when, and how their organization will respond. Although the broader issue of cybersecurity is outside of the scope of his report, Lohse said the value of medical information coupled with cost pressure and financial incentives will likely impact fraud, waste and abuse in years to come.
"Privacy and security is something [outside of] predictive analytics and the rules in which you process claims, but you can see that water finds its course downhill," he said. "Where there is pressure to create fraud, waste and abuse, payers have to defend themselves. I just see a lot of pressure in the system and that's a lot of pressure that creates leakage."
Related Articles:
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How a strategic approach to data will advance fraud prevention in healthcare
How states and payers can make better use of data to thwart fraud
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