By Theja Birur
'Fountain of Youth' Doctor Fraud Is Now Preventable
The fraud, waste and abuse (FWA) cases and convictions being prosecuted by the Department of Justice point to the rising sophistication and negative impact a single provider, or small group of providers, can have on the healthcare system. The recent conviction of a physician known as the ‘Fountain of Youth’ doctor is the latest example of fraudulent activity that is now detectable and preventable using the 4L Data Intelligence patented Integr8 AI technology platform based on real-time and continuous machine and deep learning.
A Fox Chapel, PA cardiologist was sentenced to six and one-half years in prison on August 5, 2021 for his role in a fraud scheme involving more than $13 million in false insurance claims, according to the Pittsburgh Post-Gazette.1 The fraudulent behavior occurred between 2008 and 2013 and included claims submitted to private health insurance companies as well as government insurance programs for an outpatient treatment called External Counter Pulsation.
These same common fraud characteristics can now be detected and prevented…
A Textbook Example Of Fraudulent Billing Behaviors
Dr. Samirkumar J. Shah’s was a textbook for how providers have been able to commit fraud in the past. These same common fraud characteristics can now be detected and prevented BEFORE fraudulent claims are paid. When you examine the characteristics of Dr. Shah’s fraudulent behaviors you see the following behaviors that are common in fraud cases:
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Billing across multiple health insurance plans
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Over-use of a specific diagnosis code
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Over-prescribing of a DME product
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Over-prescribing a single diagnostic procedure
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Activity across multiple jurisdictions (multiple states)
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Billing for services that were not physically provided
So, what’s the answer to detecting and preventing healthcare fraud like that committed by Dr. Shah? The 4L Data Intelligence FWA Prevention & Recovery solution, powered by Integr8 AI reduces healthcare fraud, waste and abuse (FWA) by automating real-time financial, clinical and behavioral data insights that help detect, prevent and recover fraudulent claim payments.
The blatant anomalies in his claims would have been identified in near real-time using Integr8 AI .
Detecting Anomalies Is Key To Stopping Fraud Before Payments Are Made
The key to stopping fraud before payments are made is detecting anomalies in relationships, behaviors and outcomes in a way that immediately and continuously reduces risk. Automated structured and un-structured machine-learning empowers 24/7 surveillance of financial and clinical claims data and interrogates every claim against millions of data points including ICD-10 codes, CPT codes, payer guidelines, collusion maps, patterns and relationships with other providers. More importantly, this technology interrogates each provider’s behaviors and relationships around a claim and in relationship to other providers across all claims to identify FWA patterns and trends that help to identify FWA risk before it becomes a big problem.
In addition, the 4L Data Intelligence proprietary database of 7 million providers adds another powerful layer of financial and demographic sophistication to this surveillance. In doctor Shah’s case, the blatant anomalies in his claims would have been identified in near real-time using the Integr8 AI artificial intelligence technology platform.
Return Healthcare Dollars Back To The Healthcare System
FBI Special Agent in Charge, Robert Jones said, “Health care fraud is a fundamental problem that impacts every American. It takes critical resources from our health care system and increases health care costs for everyone.”
My work in both the Canadian and American healthcare systems showed me the extent to which care quality and quantity are compromised because of fraudulent actors. Our initial commercial deployment of the 4L Data Intelligence FWA Prevention & Recovery solution, powered by Integr8 AI showed us that this fraud, waste and abuse involves a range of 1.5 to 20 percent of providers depending on the network.
Most fraudsters’ relationships, collusions and behaviors are generally the same, and they are now detectable in real-time. That is why I was motivated to build the Integr8 AI artificial intelligence platform. Healthcare needs this type of technology to fix what is estimated to be a $700 billion problem in the United States.
1 Torsten Ove, Pittsburgh Post-Gazette, August 5, 2021
For more information about the 4L Data Intelligence solutions discussed in this story, please contact us at info@4LData.com
Theja Birur Chief Technology Officer & Founder
