By Theja Birur
Surfers talk a lot about sets, groups of waves that keep coming one behind the other. While that may be a surfer’s dream, the continuous cadence of telehealth fraud, waste and abuse stories is looking more like sets of tsunamis coming one after the other.
The dollar amounts of charges brought by the U.S. Department of Justice for telehealth and telemedicine fraud are staggering. Indictments for $4.5 billion and $1.2 billion are just the tip of the iceberg in a telemedicine market that is growing by 26.5 percent per year and expected to reach $475 billion by 2026. It’s a big market with a big fraud, waste and abuse problem.
The Common Characteristics of Telehealth Fraud, Waste and Abuse
When examining some of the telehealth or telemedicine indictments a few common characteristics scream off the page. Relationships between dishonest doctors, pharmacies, labs and equipment or supplies providers are endemic in almost every case. In short, collusion between bad actors is part of each major fraud case.
The other common characteristic is that it does not require very many fraudulent providers to do a lot of damage. In a Florida telehealth fraud case announced May 3, 2021, the Department of Justice charged only three men in a $47 million healthcare fraud, kickback and money laundering scheme. In the $4.5 billion case referenced above, 86 providers were charged. And the $1.2 billion case involved only 24 people. Those are all very tight knit groups of providers united to engage in telehealth fraud.
The Solution Part 1:
Detecting Problem Providers, Behaviors and Relationships
Healthcare payers including government agencies, private insurers and self-funded employers are all asking the same question, “How can we detect bad actors BEFORE they have the opportunity to commit fraud”. The answer lies in using advanced artificial intelligence technology to connect-the-dots between structured and unstructured data from related and unrelated sources.
4L Data Intelligence was recently awarded a core technology patent for our Integr8 AI™ data intelligence platform that powers a machine-learning model trained using representations of a set of resource requests and authorization determinations to identify and adjudicate behaviors and transactions that are representative, or predictive of operational threats. In simple language, our 4L Data Intelligence Provider Intelligence & Integrity solution, powered by Integr8 AI, can be used to identify problem providers, relationships and behaviors in real-time. Here is how it works.
The 4L Data Intelligence Provider Intelligence & Integrity solution, powered by Integr8 AI uses provider data, payer data, public data and our own proprietary database of 7 million NPIs to immediately and continuously detect problematic activity in any provider network. The immediate output is detection of unauthorized providers, fraudulent providers operating under aliases, potentially fraudulent providers and potential collusion and relationships that point to fraudulent intent. And, because fraud and fraudulent providers are dynamic, the 4L Data Intelligence Provider Intelligence & Integrity solution, powered by Integr8 AI provides continuous surveillance to detect changes in provider demographics, status, behaviors and relationships that are indicators of new fraudulent behaviors.
The Solution Part 2:
Detecting and Preventing Problem Claims Transactions
Immediately and continuously identifying potentially fraudulent providers is one-half of the solution. The other half is detecting potentially fraudulent claims BEFORE they are paid.
4L Data Intelligence FWA Prevention & Recovery solution, powered by Integr8 AI™ reduces healthcare fraud waste and abuse by automating real-time financial, clinical and behavioral insights that help detect, prevent and recover fraudulent claims payments pre-adjudication. The power of Integr8 AI™ automated machine learning literally enables every claim to be analyzed with millions of combinations of CPT, ICD-10 and other code data along with payer guidelines and the provider network data.
This powerful fraud-fighting solution is on 24/7 empowering payers to stay ahead of fraudulent providers and reduce the amount of FWA leakage that gets through the system.
Telemedicine is a Great. Keep it Clean and Efficient.
4L Data Intelligence is committed to providing the data insights to help healthcare payers immediately and continuously reduce risks to improve clinical and financial performance. Our Integr8 AI™ powered solutions provide a much-needed technology to keep the telehealth and telemedicine markets clean and healthy.
For more information about the 4L Data Intelligence solutions discussed in this story, please contact us at info@4LData.com
Chief Technology Officer & Founder
