Predictive Analytics

Analytics a major part of health care’s fight against fraud

By July 30, 2015 No Comments

Fraud is among the most significant and expensive issues the health care system deals with these days. Sullied data, embezzled funds, fake claims, mysterious gaps in accounting – all of these crimes drain the industry of resources that could be better utilized elsewhere. In 2012, the effects of fraud and the funds allocated to fight it cost the entire health care system a jaw-dropping $272 billion, according to The Economist.

Advancements in technology and a greater understanding of analytics lead the charge in fraud detection. As more data is gathered, insurance and health care companies can fight the attackers who have taken advantage of the system for years. By utilizing improved security measure and relying on predictive analytics, companies can go from being in a vulnerable position due to fraud to an offensive one.

Start with security
As more data breaches take place, more health care companies invest in digital security. With so many medical records and other pieces of classified information now available online and through cloud-based computing software, security is the first place businesses turn in their fight against fraud, according to the Association of Certified Fraud Examiners.

"These breaches have exposed widespread vulnerabilities among organizations that store and maintain personal information, putting millions of individuals at risk," said Bruce Dorris, the vice president and program director of the ACFE. "Considering that storage of data continues to grow at an exponential pace, more trouble lay ahead – and there is an increasing need for information security and protecting against data breaches."

At the forefront of the health care industry's security upgrades are analytics. Studying data allows professionals to detect the trends within a network. Finding these patterns helps a company identify the problem areas it must address.

The process of gathering health care data, followed by organizing and analyzing the information, is a lengthy one. Yet innovations in analytics have made the process much more efficient and important to companies looking to combat fraud, according to Venture Beat. Big data software programs allow health care companies to combine all of the information they collect – no matter where it came from, how large it is or what format it is in – to find those trends.

By creating security interfaces that make it tougher for criminal to access health care and insurance websites , medical companies hope to take a step ahead in fighting fraud.

Assistance through predictive modeling
Analytic software can review previous examples of fraud and find common threads among these instance. From there, security experts within the health care industry are on the lookout for those types of fraud in the future.

That strategy is called predictive modeling, and it is an important weapon in the health care industry's battle against fraud. By understanding tactics and approaches criminals used in the past, businesses in the field believe they can be more prepared for threats in the future. Because of its effectiveness, more health care companies are looking to stop fraud through predictive modeling software, according to Modern Healthcare.

Predictive modeling is not new to analytics or even fraud prevention, as Forbes pointed out in 2014. However it can still be useful in detecting illegal claims before payment is made to the wrong people.

Utilizing predictive modeling in 2013, the Centers for Medicare & Medicaid Services prevented more than $210 million worth of fraud, the agency reported in June 2014. Yet as thieves continue to find new ways to attack the health care industry, the technology to stop them must evolve at a faster rate.

While the system is not perfect, updates to the technology give companies greater insight as to how thieves work to defraud a business. The data gathered from predicting how criminals attacked in the past can be tremendously useful for a health care company looking to prevent fraud in the future. 

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