The more things change, the more they seem to stay the same. That's particularly true when it comes to the cyclical nature of healthcare fraud, says Jack Price, former chief security officer and special investigations unit (SIU) director for Blue Cross Blue Shield of Tennessee in an exclusive interview with FierceHelathPayer: Antifraud.
Predictive analytics, emerging concerns surrounding medical identify theft and two major payer mergers have certainly altered the fraud prevention landscape, but fraudsters are continually looking for gaps in the system, says Price (pictured right). Just when SIUs think they have all their bases covered, an old fraud scheme resurfaces.
FierceHealthPayer: Antifraud spoke with Price about the current fraud climate, concerns surrounding medical identity theft and--in light of recent health insurer mergers--potential issues that arise when combining two large SIU departments.
FierceHealthPayer: Antifraud: What kinds of issues are SIUs focusing on in the current fraud climate? Are there particular fraud schemes or billing patterns they are looking for?
Price: These schemes never go away. In music appreciation, you learn about variations on a theme, and I think the fraud world is very much the same. What works today may not work tomorrow because the payers have found a way to close that window of opportunity, or at least close it part way. So the fraudsters have to come up with a variation in order to get paid.
And old schemes seem to be born again after a few years. Nobody sees them and then they come back. In today's world of technology, it makes it a little easier because you can load all this into your system and the system does not forget about the old schemes, so they can identify them. But no matter what you do as a payer, the other side is working just as hard to get by whatever you put in their way.
So, is there something brand new out there that no one has ever seen before? I kind of doubt it, but with the change in the healthcare system there is going to be opportunities to steal, and it doesn't take long for them to find that and exploit it.
FierceHealthPayer: Antifraud: You mentioned new technology. How has the use of predictive analytics changed the approach of SIUs?
Price: I'm not sure what the percentage of payers using those systems stands at. In the past, everyone was very interested in getting applications and the vendors were all out there selling applications, but very few payers would pony up the money right away for something. Looking back at my own career, it took years to get one of those in-house. And you don't just need just one, you need more than one, because each system does something very well, but none of them do it all perfectly, so a lot of the more successful SIU operations had access to more than one analytics system.
Then the big thing was to stop the money before it goes out because a lot of the systems were designed to use historical data to go in and mine that, find your behavior, and then go after it and try and get the money back.
Everyone decided we need to catch this before it goes out of the house. Predictive analytics came to be and I think there was--and is--great promise there to be able to help stem the tide on fraudulent claims. But I really don't anticipate that there is ever going to be a silver bullet that you can plug into your system and you're going to catch everything.
FierceHealthPayer: Antifraud: This year has been the year of healthcare data breaches. How do those impact SIU operations in terms of mitigating the damage of compromised personal health information?
Price: I think one of the biggest things that payers will face this year is an increase in medical identity theft. I won't say it's the newest thing out there because it's been around for years, but it's getting more playtime and people are developing ways to utilize those identities to steal money. And that's going to be big issue going forward.
FierceHealthPayer: Antifraud: How much of that has to do with cybersecurity issues and keeping pace with hackers?
Price: You can have someone that works at a provider's office or an insurance company steal identities, and some of them can steal quite a few, but that pales in comparison when someone hacks the system and steals millions of identities.
[SIUs] can watch for activity on any of these things. I know there are some companies out there [that] have applications that help identify potentially bad claims on identity theft victims, but they can wait years before they file the first claim.
Then there are all kinds of schemes that they can come up with. One of the things I faced in the past doing life insurance and death investigations, was that in Los Angeles, you could go on the street and purchase a death kit. The death kit had verifications from a country's government and they were stamped and looked very official. They were all blank and you could fill them out the way you wanted to and you would file for life insurance.
FierceHealthPayer: Antifraud: Over the last few months we've seen two major proposed mergers between Aetna and Humana and Anthem and Cigna. How does a merger like that impact SIUs within those organizations? How do you navigate the merger between those two departments, and what potential issues might they run into?
Price: You always run into the issue of who's in charge. I went through one of these that wasn't just for healthcare, but the merger we had, they came in and said they were going to do a study and look at industry best practices and then that's what we're going to do.
We were all very hopeful because we were the company that was acquired and we knew we were doing things that were pretty cutting edge.
They came back in about a month and said, "OK, we did our study and our way is the best way, so we're going to do that." You're kind of standing there dumbfounded, knowing that they didn't even really look at it.
I don't know if that would be an issue, but any time you combine two operations, some things are going to get left behind and fall out, and of course you don't need the same amount of staffing because that's one of the reasons for the merger is to cut back on head count. Unfortunately, a lot of the payers seem to look at the SIU operations to cut expenses.
FierceHealthPayer: Antifraud: Are there ways to make that process go smoothly?
It depends on the personalities involved. I hate to say that, but it's true. What are the personalities of the people involved that head up each SIU operation, and are they going to get along with each other? Are they going to make sure they triumph in the way things are done and keep their people?
The easiest thing in the world is for someone in that situation, and I've experienced it, where they come in and say, "OK, we have to cut 10 people." And you say, "OK, five each?" They say they are going to evaluate everyone and it turns out eight of the 10 come from one company, whoever is weaker.
It can be [a power struggle] depending on the personalities involved. I know the people involved in both of these mergers and I don't think they will face those issues, but I'm not sure what else they will face.
Editor's Note: This interview has been lightly edited and condensed for clarity.