Proven AI technology offers an efficient and scalable approach for combating fraud, waste and abuse
We recently hosted a webinar on using AI to mitigate the $240 billion healthcare fraud, waste and abuse problem. Jala Attia, President, Integrity Advantage, served as moderator, and Beth Griffin, Vice President, Healthcare Product Development and Innovation, Mastercard, and Tim McBride, Director, Healthcare Product Development and Innovation, Mastercard, were the speakers.
Already a leader in fraud and security, Mastercard leverages its proven AI technology to bolster detection of true fraud, waste and abuse. As a result, false positive alerts are greatly reduced for special investigative units (SIUs), anomaly detection is significantly increased, and payers are able to focus their SIUs on highly likely fraud. Webinar attendees learned what makes Mastercard technology uniquely successful in FWA mitigation in an efficient and scalable manner, including its superior ability to:
- Reduce false positives by 20 times
- Apply a proactive defense by adapting to changes in real time
- Provide continuous, automated updates to the AI model based on actions taken and any changing behaviors
- Learn a final disposition of the case and claims that impact the outcome
- Identify new patterns of behavior not previously known
Tackle real-world healthcare fraud scenarios head on
Webinar attendees also gained insights into specific patterns and codes within their own healthcare payment data that could be indicative of fraud, such as a patient’s age, the type of treatment provided, any instances of advanced care and/or a history of testing. Beth and Tim walked attendees through real-world scenarios of fraud challenges Mastercard has addressed head on, including how its AI identified a provider billing for intrathecal injections for the treatment of Spinal Muscular Atrophy in a manner that was inconsistent with FDA/manufacturer instructions. Beth and Tim also shared how Mastercard AI identified claim waste for unnecessary 3D modeling from an OB/GYN biller, as well as unnecessary and excessive genetic and molecular pathology testing for a 65-year-old hospice patient.
Ultimately, Beth and Tim explained, the goal of mitigating FWA is to reduce the cost of healthcare so that all parties involved – especially patients – are positively affected. You may access a full replay of the webinar here. For more on how Mastercard is addressing FWA and driving efficiency for SIUs without introducing additional risk, download our Ebook about healthcare FWA here.