In our ongoing AI Innovators Series, we’ve presented leaders in artificial intelligence talking about using AI in new or original ways. This week we’re bringing you Beth Griffin of Mastercard who explains how solving healthcare fraud, waste and abuse (FWA) can be dramatically improved with AI.
In an industry where 80 percent accuracy in alerts of healthcare FWA is considered good, Mastercard’s VP of Healthcare Product Development and Innovation challenges the norm. Beth Griffin and her colleagues are on a mission to drive that number down just as they have with payments fraud.
“Sixteen years ago, Mastercard took a financial services market that wasn’t detecting fraud very readily, implemented Brighterion AI into our payment network. We were able to identify fraud and stop it in its tracks – on a real time basis at scale,” Beth says. “We revolutionized the payment market. That’s exciting! Now we’re taking that technology and implementing it in the healthcare market, specifically around FWA.” Mastercard acquired Brighterion in 2017.
Using AI to tackle FWA
As Beth points out, healthcare insurers are generally focused on fraudulent claims after they are paid. That’s problematic, of course, because many fraudsters have taken the money and moved on. Only 5-10 percent of the $240 billion paid out for fraudulent claims is ever reimbursed, or between $12 billion and $24 billion.
AI can create prospective (pre-pay) models built by identifying anomalies found in historical claims data (post-pay). The pre-payment model identifies FWA before the payer sends good money for bad claims, significantly reducing the need for inefficient pay-and-chase activities.
Since the technology enables live updates to existing models based on real-time claims experience, Mastercard AI reduces “digital noise” and automates most of the manual processes currently used to maintain and update existing rule-based technology.
The result is significantly reduced false positives, allowing investigators to pursue actual fraud.
A final note: our healthcare FWA solution is built by former healthcare administrators, FWA investigators and top AI computer scientists. With outcomes based on in-the-trenches experience, Beth says, “Organizations can expect a very strong return on their investment from us because we’re coming in with an extremely strong, proven technology that can drive up their detection rates and drive down their false positives.”
