A smarter fight against fraud

By | 1 minute read | January 22, 2021

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For Medicaid integrity programs, the fight against wasteful spending and fraud is a never-ending burden. The good news is that augmented technologies are available to help investigators make the most of their resources and fight back smarter.

Even for agencies with robust programs, reclaiming funds can be really difficult. For example, in the United States, the Department of Health and Human Services found just over USD 100 billion was misspent in Fiscal Year 2019.1 Although federal prosecutors filed charges to reclaim funds that were lost due to fraud and abuse, they only recovered over USD 2 billion in judgments and settlements.2

Programs with increasingly limited staff and budgets have fewer options for monitoring payments, and when they do find waste, fraud, or abuse, they often have to choose which investigations would make the most financial sense to pursue. Those are tough choices, and investigators need every advantage they can get. With innovative technology insights on their side, investigators could be more efficient and thorough, which could ultimately give them more opportunities to reclaim payments based on fraud, waste, and abuse.

IBM Watson Health® regularly shares a set of key fraud-fighting algorithms that are prepared by our program integrity analysts, Accredited Health Care Fraud Investigators, and subject matter experts. These algorithms help uncover common forms of waste and abuse, such as duplicate claims, inflated charges, and unbundling.

For example, our telehealth algorithm can be used to determine if medical claims are being billed according to the appropriate telehealth policy. By helping investigators identify outliers who might be billing improperly, this algorithm could help them save time as well as speed up the processes for uncovering billing mistakes, improper claims, and fraud.

To see how you can put IBM’s algorithms to work in your public program, watch the webinar.

Learn smarter ways to fight fraud.

  1. “U.S. Department of Health and Human Services Met Many Requirements of the Improper Payments Information Act of 2002 But Did Not Fully Comply for Fiscal Year 2019” U.S. Department of Health and Human Services, May 2020, https://oig.hhs.gov
  2. “Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2019”, U.S. Department of Health and Human Services, June 2020, https://oig.hhs.gov