Combating Fraud in Healthcare: Merging Industry Forces to Detect FWA

America’s healthcare system loses up to $300 billion to fraud, waste and abuse (FWA) annually. To successfully detect and prevent FWA within the healthcare economy, Verisk Health has launched a cutting-edge preventative approach. With the help of our initial partners, Humana and Centene, we’ve begun pooling cross-payer data from 8 million lives across 41 states and 800 thousand providers. By leveraging big data and analytics, we’ve already seen results, which are accelerating the detection of evolving criminal trends and the prevention of sophisticated FWA schemes.

Here's how our new cross-payer initiative is working to provide participants with greater access to valuable insight:

1. Better Analytics through Data Pooling

• 360-provider views
• Deviance analytics and predictive models
• Complete patient histories across providers

2. Better Collaboration through Best-Practice Process Links

• Real-time proactive alerts
• Case management and tracking
• Law enforcement referral and support

3. Better Insights through Shared Knowledge

• Regular roundtable meetings with other member
• Case study and best practice reports
• Fraudulent provider updates across members

Modern Healthcare recently spoke with our senior vice president of fraud solutions and analytics, Karthik Balakrishnan, about our pooled-data alliance and its implications for future fraud detection.

To fight increasingly sophisticated schemes, you need a more sophisticated approach. Learn more about what Verisk Health can do to help here, and view our prerecorded webinar, Pooling America’s Healthcare Data.