Tuesday, April 23, 2013

Can EHR Help Avoid Healthcare Payer Fraud?

Data analytics is a powerful tool.  When I worked in technical operations for a consumer-based technology service provider, we relied very heavily on DA to identify, diagnose and very quickly fix problem areas. In short, DA is the process of analyzing large sets of data, identifying unique characteristics of particular behaviors, and then revisiting the entire data set to find other entries that have those same characteristics.

Based on an article I just read, our government is [wisely] going to apply DA to healthcare claims in order to detect fraud.  The article identifies four ways that investigators are zeroing in on fraud.  As an example of one of the four, imagine that a doctor submits claims for the same lady giving birth twice in a 6-month period.  We can safely presume that this is a false claim... certainly one deserving investigation. To see if this is an isolated incident or a broad issue, regulators can search their entire claims database for similar behavior.  The findings will reveal the magnitude of the fraud as well as identify the biggest offenders.

You can read the article here.

The question that the article prompted me to ask is whether EHR providers will be tracking the payer's "traps" and building some sort of "red flag" mechanism into their product sets to help physicians avoid fraud accusations. I don't yet know the answer.

I'd be interested to hear your thoughts... you're welcome to comment here or email them to me at the email address in my "contact" section.