Moda Health turns to automated fraud prevention to help protect members

Moda HealthAs insurers look for ways to fight healthcare fraud and identity theft, one insurance company is turning to automated alert system to offer real-time identity theft monitoring and fraud resolution for its beneficiaries.

This month, Moda Health, an insurer based in Portland, Oregon, announced that it would be incorporating the MIDAS Alert system, developed by ID Experts, into its plans as a way to help members identify false claims. The built-in, automated alert system provides text or email notifications any time a new claim is submitted under a beneficiary's name. If there is a suspicion of fraud, ID Experts will investigate the concern.

In an exclusive interview with FierceHealthPayer: AntiFraud, Katie Paullin, director of marketing for Moda Health, talked about the reason the insurance company opted to provide this option to its members and how the new tool will limit cases of identity theft.

FierceHealthPayer: Antifraud: Why did Moda Health decide include the option for built-in medical identity fraud prevention into insurance plans?

Katie Paullin: I think we all understand that, as electronic health records (EHRs) become more standard in healthcare, there is chance for fraud to happen. At Moda, we're committed to protecting the health and well-being of our members, and offering this just seemed like a natural way for us to continue our charge and our mission to help our members be better.

FHP AF: Was there something that stood about MIDAS in particular?

Paullin: We all know identity theft happens, and we've seen breaches. I think ID Experts is one of the first companies going out and looking to see how the changes to EHRs might affect our personal health, and making sure it builds a product that will solve that. ID Experts has been out in front solving this problem from the beginning.

FHP AF: In what ways does this make it easier to keep track of fraudulent activity or identity theft?

Paullin: Our Moda members are offered this product and they choose to sign up. It's all through an online interchange, either on your phone or your desktop. As soon as MIDAS gets an alert that something has happened on that member's health record, it sends something out to the member.

I think this does a couple different things: It's making sure the member sees it in real time, and it's helping them define what that means in terms of coding. We all know we use medical codes, so MIDAS breaks that down for them to understand. It's just a nice, easy way, with an intuitive user interface, for people to see this is where it says I went, this is what happened when I went there, and is that true or not true?  If it's true, then I'm good. If it's not true, MIDAS will research it for us and protect the member.

It makes it a really simple user interface, highlighting in real-time what is going on, so people can stay on top of their health the same way we all stay on top of our bank and financial information.

FHP AF: The release points to a study from the Ponemon Institute that indicates 56 percent of patients do not check health records for accuracy. Why do you think that is? Is fraud simply not a primary concern for patients?

Paullin: Ten years ago, none of us thought that our medical identity would be stolen. We didn't think about the ramifications of that. It's something new. We're just not accustomed to protecting that information the same way we've been taught to protect our financial information.

Unfortunately, the product exists because bad people are doing bad things. Luckily, the product is teaching us all to pay attention to what is happening, not only in our financial health, but in our personal health as well, and making sure we're following and keeping track of all that.

FHP AF: In what ways is this going to help you, as a payer, in terms of saving money and preventing those instances of fraud and abuse?

Paullin: Well, we know that fraud exists, and this is protecting our members. One, we want to make sure we are protecting them for their safety. We're really focused on making sure our members are safe all the time, so this is one way we offer that protection.

Two, it helps protect these higher healthcare ecosystems from fraud. It's helping our members so that they aren't stuck with a bill that isn't their responsibility, it's making sure that actual services are rendered, and making sure that everyone is kind of staying true in terms of the care they are getting. But for us, it's about the protection--protecting members' health information, protecting their wallet, and making sure we're taking care of them in a way we should be.

FHP AF: Is part of this decision based on the large fraud cases that have emerged over the last several years? Has it reached a point where you have to protect those kinds of finances?

Paullin: I think it's more about protecting people's health at the end of the day. Does fraud exist? Sure it does, but it's really more about, at the point of care, if the patient showed up at a hospital unconscious and there is something on their health record because of fraudulent activity, that will hurt them or potentially be a fatal decision because their EHR is wrong. It's making sure people get the right care at the right time because their medical record says the right thing.

FHP AF: Do you think more payers will turn to automated fraud detection as a way to prevent fraud and reduce costs?

Paullin: I can't say what other payers will do, but I do think it's important to protect members and patients, so I think people will be looking at all sorts of automated ways to take care of that.

[Editor's Note: This interview has been edited and condensed for clarity.]