Study: Fraud incentives and countermeasures

Against a backdrop of incentives for healthcare fraud, business researchers at Aberdeen Group explain how organizations use data integration, automation and analytics to battle the crime.

"Healthcare fraud affects virtually every citizen and consumer in terms of higher cost and greater risk to personal privacy," their study concludes.

Fraudulent billing often follows identity theft, and rates of this crime are rising. Between 2012 and 2013, the number of medical identity theft victims grew by 19 percent, as FierceHealthPayer: Anti-Fraud reported.

Criminals pay only $20 for basic identity information on the black market, the study noted. This information includes names, birth dates and health insurance contract and group numbers. But deluxe, ready-to-use identity theft kits fetch a price of nearly $1,500. Kits contain Social Security numbers, banking credentials, credit card information and PINs, as well as custom-made physical credentials related to the stolen identity. These credentials include insurance membership cards, Social Security cards, driver's licenses and credit cards.

In view of the high cost of fraud, "leading organizations are justifying investments in the means to disrupt the economics of the criminal's business case: Lower reward and greater risk of getting caught," the report states.

The study tells the success story of a national healthcare system's use of data integration and analytics to stop information theft by employees. The provider consolidated data sources for patient information from eight legacy systems to a centralized software platform, the report noted. Then it developed the capability to spot an abnormal number of pageviews in real time and send alerts. The new system also helped the provider self-monitor documentation changes intended to inflate medical billing.

Overall, Aberdeen researchers found quicker detection correlates with lower fraud loss among "leading solution providers," which are companies that integrate, automate and analyze to counter fraud "across a broad observation space."

For more:
- here's the Aberdeen study report (.pdf)

Suggested Articles

The HHS OIG is asking for an additional $23.7 million to support fraud oversight that has benefited from an emphasis on data analytics.

A New York surgeon was sentenced to 13 years in prison for fraud and more physician practice news from around the web.

A federal judge has ruled that the U.S. government’s remaining fraud case against UnitedHealth can move forward.