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Before 2020, telehealth was mostly an afterthought. Most “telehealth” consisted of people looking up their symptoms on WebMD.

A few months after March 2020, telehealth represented nearly 50% of all medical appointments.

Telehealth is more convenient for patients – convenient enough that many will be loath to give it up even once the pandemic subsides. The problem is that these conveniences also created openings for telehealth fraud. Many insurers were taken by surprise.

  • Greater access to doctors led to providers upcoding smaller visits and billing for services not rendered.
  • Patients also had greater access to their own records – which meant that fraudsters altered these records to misrepresent the kind of services they provided.
  • Lastly, telehealth led to faster prescription renewals, which prompted fraudsters to generate excessive claims or attempt to bypass lock-in requirements.

Since the pandemic began, fraud schemes related to telehealth have cost health plans billions of dollars. Insurers found themselves unable to get ahead of  the ramifications of this change to healthcare, which left them more vulnerable. How can they prepare for the next sea change in the way that members access care?

Disruption Isn’t Done with the Health Insurance Industry
Healthcare is trending towards less traditional approaches. As patients in more rural areas find themselves further away from hospitals and doctors offices, they’ll tend to consume medical care at less traditional venues. Drive-through testing and prescription refills, minute clinics at drugstores, and urgent care centers all offer ways for patients to quickly receive professional care without a long trip – but some of these resources can act in less than ethical ways.

For example, we might see minute clinic providers deciding to bill half an hour for a five minute consultation. Drive through testing centers might decide to bill using E&M codes (regardless of the fact that this is prohibited). We’ve also seen urgent care centers bill Medicaid and Medicare after providing treatment from uncredentialed doctors.

In other words, these less traditional approaches have made it harder for health plans to detect and mitigate fraud within their provider networks – and this is just one of many trends facing the industry. In the near future, insurers could see big changes to nationwide healthcare laws, a new drug or viral epidemic, or even the mass resignation of critical doctors and nurses.

Health plans need to get ahead of this by planning for disruption. At our recent webinar on Wrangling Telehealth, experts from Shift Technology spoke with Shemeeka Jones, the Senior Manager of Special Investigations at Magellan Healthcare and Jala Attia, the President and Founder of Integrity Advantage. Here’s how their experience can guide health insurers to prepare for future disruptions.

Lesson 1: Ditch the Yearly Risk Assessment
Perform risk assessments more often than once a year—and always perform a risk assessment once a major disruption occurs. This lets you identify risks within your health plan.

Lesson 2: Replicate Best Practices within Your Provider Network 
Each health network will contain trusted providers. Work with them to understand how they’re planning to react when changes occur. This helps you understand the behavior patterns of a known good provider, and allows you to flag anomalies.

Lesson 3: Think Like a Fraudster
What would a criminal do to exploit changes in the health insurance environment? You’ve spoken with your trusted providers to understand how they’ll react to a systemic change—now use that input to understand the loopholes in a new payment or treatment system.

Lesson 4: Look into other data sources 
Your first-party data is valuable, but incorporating external databases can help you triangulate bad behavior. These can show you when practitioners are sharing patients, expose double billing patterns, and highlight billing for services not provided. One example – a surgeon bills for a procedure, but social media photos show vacation pictures posted that same day. Incorporating third party data lets you see beyond the official reports.

Lesson 5: Get Buy-In to Empower the SIU
Empowering the SIU with more budget and resources doesn’t just make the department more efficient in identifying suspect cases. It also provides the ability to collaborate with other lines of business within the health plan to improve aspects such as prepayment detection. In other words, health payers will be able to do more than just chase false claims after they’ve been paid.

Shift Technology Gives You the Tools to Cope with the Next Big Thing
Using Shift Improper Payments Detection, health plans can empower the SIU to conduct faster investigations and make better decisions about identifying fraud. Improper Payments delivers a high impact  approach to investigations, allowing the SIU to prioritize cases by potential value to the plan. By tackling the largest cases first, investigators can reclaim more revenue, faster. Meanwhile, the AI-powered approach allows insurers to detect novel forms of fraud, allowing health plans to get ahead of a changing industry landscape.

For more information, watch our on-demand webinar today.