The United States spends about $2.6 trillion annually on health care (17.5 percent of GDP) and with the reform initiatives under the Affordable Care Act (ACA), the number of Americans covered and the amount spent will grow dramatically, potentially leading to even greater fraud, waste and abuse in the system. In 2013, the U.S. Department of Health and Human Services estimated that it improperly spent about $65 billion in taxpayer funds through waste, errors and fraud – with $60 billion attributed to overpayments to Medicare and Medicaid.
Historically, claims data has been the sole resource for investigators to mine data from in order to identify overpayments. However, implementing public records data into a core claims detection program can greatly enhance a payer’s ability to uncover derogatory attributes linked to providers and other individuals across the health care system.
One thing is clear — traditional methods alone are not adequate to face the ever changing and more complex schemes and methods. Leaders and decision makers need to question whether the tools they have allocated to combat today’s health care fraud, waste and abuse are still effective for countering today’s risks. The use of public records data can help strengthen a case by providing information that is not found in claims data alone, such as license status, criminal convictions and other high-risk indicators.
Learn more about how public records can be integrated into fraud, waste and abuse detection and prevention models by downloading this white paper.