The Corruption, Misuse and Consequences of Fraud, Waste and Abuse: Part 1

by Tonya Veltman

I have been in the insurance industry for more than 20 years, and inside of a fraud unit for the bulk of my career. After all this time, I still often wonder what motivates people to commit benefit insurance fraud. What drives regular folks to “break bad” and risk losing their reputation, their employment or even their family just to bring in a few extra dollars or to take “full advantage” of their benefit plan?

What creates that pivotal moment where someone makes that decision to alter a receipt or create one from scratch? How does one decide to pay off a care provider to obtain a “legitimate” invoice to then turn around and submit to their insurance carrier for reimbursement?  What makes them think the behaviour is okay and how do they convince themselves they won’t get caught in a world where technology reigns supreme?

I truly wish more employers reinforced at the time of enrolment (or even re-enrolment) that benefits fraud is a crime.  Ultimately, it makes no difference if you falsify a claim once or if you submit multiple false claims over a period of time – fraud is fraud and comes with consequences.

What exactly constitutes benefit insurance fraud?
Benefits fraud occurs when a clinic, facility, provider or practitioner intentionally submits false or misleading information about their treatments or services for the purpose of financial gain. Benefits fraud also occurs when a plan member or dependent under the plan member submits false, altered or misleading information about their own claims or those of their dependents. Ultimately, benefits fraud can be committed by a health care provider, a health care supplier, a dental provider, plan members, plan sponsors, or in instances of collusion, all of the above.

Another pressing concern for insurers is of course, waste and abuse, which also often leads to consequences when detected. Waste occurs when someone overuses health care services, while abuse can be defined by an individual or group of individuals who submit expenses under their healthcare plan for products and/or treatment that were not necessarily needed or when medical best practices are not followed. 

How do people get caught committing benefits fraud?
Insurance companies everywhere have been engaging in the use of systems and technology that allow them to detect and review both suspicious and fraudulent claiming activity. The bulk of insurance companies now have various sized investigative teams (often designated Special Investigation Units – SIU – or Fraud and Risk Management Teams) made up of individuals employed to conduct audits, review suspicious claim submissions, investigate tips from varying sources and handle both small- and large-scale claims investigations related specifically to Fraud Waste and Abuse (FWA). 

More and more frequently, insurance companies are employing the use of tools, systems and technology to aid in their detections of fraud, waste and abuse.  One of the tools used includes the use of Artificial Intelligence which is the simulation of human intelligence and actions through machines. The machines are programmed to think and perform like humans and can mimic both problem solving and decision-making capabilities.

This use of Artificial Intelligence technology can help Health Insurance carriers drive growth through both innovation and investment from day one and can do this by being very specific in their line of focus. At Shift Technology we partner with benefit carriers and are 100 percent focused on insurance. As such we pride ourselves on our globally expanding footprint and presence within the insurance space.

Now that we have a sense of how benefit insurance fraud may be impacting payer organizations, we will explore what Shift Technology can help do to mitigate it in Part 2.

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