The Self-Insurer Magazine
Combating Sophisticated Healthcare Fraud Schemes: Lessons for Self-Insured Health Plans
4L Data Intelligence, a leader in healthcare fraud prevention technology, is proud to announce that our Senior Fraud Advisor, Greg Lyon, has authored a featured article in the July 2024 issue of The Self-Insurer Magazine.
The article, titled “Combating Sophisticated Healthcare Fraud Schemes: Lessons for Self-Insured Health Plans,” spans pages 36-45 and provides critical insights into the evolving landscape of healthcare fraud, offering valuable strategies for self-insured plans to protect their members and health plans from fraud.
The article, appearing in the official publication of the Self-Insurance Institute of America (SIIA), draws from a recent case study of a massive fraud scheme targeting Medicare with an exposure of up to $2B. While the scheme focused on government programs, Lyon emphasizes that self-insured health plans are equally vulnerable to these sophisticated fraud schemes.
Continuing the insight, “Healthcare fraud is a massive and growing problem, costing the industry billions of dollars annually,” Lyon writes. “Self-insured health plans are not immune from these sophisticated fraud schemes. Further, when fraud occurs, plan members are at risk and valuable healthcare dollars are exposed.”
The piece outlines two key technology-forward approaches for fraud prevention:
- Implementing a provider-centric “Know Your Provider” (KYP) approach. Lyon advocates for continuously gathering and analyzing provider data in near real-time to understand their integrity, behaviors, and relationships with other providers. This approach enables payors to maintain an up-to-date profile of each provider and quickly identify potential red flags.
- Continuously integrating KYP data with historical and real-time claims data. This strategy empowers healthcare payors to analyze provider behaviors in near real-time, examining each claim in the context of historical patterns and relationships across the entire provider network.
Equally important, these strategies align closely with the capabilities of 4L Data Intelligence’s flagship product, Integr8 AI. Our cutting-edge artificial intelligence platform is designed to detect and prevent fraud by analyzing provider behaviors, relationships, and claims patterns in near real-time, embodying the KYP approach and dynamic data integration that Lyon recommends.
“The ongoing battle against healthcare fraud requires the adoption of cutting-edge technology and innovative approaches,” Lyon notes in the article. “Self-insured plans have a significant interest in ensuring that their valuable healthcare dollars are protected from fraud to the greatest extent possible.” At 4L Data Intelligence, we’re committed to staying at the forefront of fraud prevention technology. Consequently, our feature in The Self-Insurer Magazine underscores our position as thought leaders in this critical field.
We invite all self-insured health plans and industry professionals to read the full article in the July 2024 issue of The Self-Insurer, available online at https://issuu.com/selfinsurer/docs/july_2024_the_self-insurer. To learn more about how 4L Data Intelligence and our Integr8 AI™ platform can help you Find, Fight and Prevent FWA Fast™, visit 4LData.com or email info@4LData.com.
