Plan to attend our upcoming webinar to learn how healthcare firms can use innovative AI to solve the FWA challenge. The session is a collaboration with America’s Health Insurance Plans (AHIP).

If you follow our blog, you’ll know that healthcare fraud, waste and abuse (FWA) in the U.S. is a $240 billion annual problem. Mastercard Healthcare Solutions wants to change that paradigm to a practice of using innovative AI in preventing FWA.

Currently, legacy systems don’t flag evolving schemes and many fraudulent claims are paid before being identified. That leaves healthcare insurers out of pocket and trying to recover payments. According to NHCAA, only five to ten percent of fraud is intercepted, causing huge losses across the industry.

Meanwhile, fraud schemes are becoming increasingly complex and more difficult to identify with traditional payment integrity solutions. Our recent survey of 50 healthcare insurance executives revealed a desire to use artificial intelligence in their organizations.

The current climate of FWA

In a recent survey on technology use in the healthcare sector, it was revealed that only 4.3 percent of healthcare firms use artificial intelligence. The most commonly used technology solution is rules-based management (63 percent). Rooted in legacy, hard-coded technology, rules-based systems don’t update as fraud evolves. With current events bringing new and more ingenious opportunities for fraud, outdated systems put insurers at serious risk of missing fraudulent claims.

Advanced AI uses various tools including machine learning to enable automated updates based on observed actions and changing behaviors. By identifying new behaviors, it reduces false positives by up to 20 times, acutely focusing investigations on highly likely fraud. The cost savings are self-evident.

Education on artificial intelligence and FWA

On June 23, 2020, Brighterion is hosting “Preventing FWA and increasing efficiencies with innovative AI,” the next in our series of webinars. Mastercard Healthcare Solutions’ experts will look at how AI can significantly increase detection and prevention of FWA, and help move organizations towards a “prevent and save” model, versus the old “pay and chase” system.

We will also demonstrate how a company with vast success AI in payment fraud complements health claim fraud mitigation by moving from pre-pay to post-pay models.

Our presenters

We are excited about our speakers. Beth Griffin, VP, Healthcare Product Development and Innovation, Mastercard, leads Mastercard’s Healthcare Vertical with the Cyber and Intelligence team. Beth manages the healthcare fraud and AI business, building upon the healthcare payment solutions she previously managed at Mastercard. Beth was recognized by Becker’s Hospital Review as one of 110 Women in MedTech to Know in 2017. She previously served as the Chief Marketing and Product Officer for Health Payment Systems where she was responsible for the strategic positioning of HPS and led the company’s marketing, consumer engagement and product development efforts. Beth has over 30 years of experience in the financial services and the healthcare technology industries.

Tim McBride, Director, Healthcare Product Development and Innovation, Mastercard leads Mastercard’s Healthcare Fraud Waste and Abuse Vertical within the Cyber and Intelligence team. Prior to joining Mastercard, he served as an Investigator and Product Manager for Verscend Technologies (formerly Verisk Health) within the Fraud solutions team where he was responsible for algorithm and product development efforts. Tim is an accredited Health Care Fraud Investigator responsible for managing the creation and development of FWA solutions for healthcare using artificial intelligence. Tim has over 23 years of experience in the healthcare payment and technology industries.

Jala Attia, President of Integrity Advantage, rounds out the presentation team. Jala is a healthcare fraud, waste and abuse (FWA) expert with nearly two decades of detection, investigation and program oversight experience. She held integral roles in building and cultivating a multi-million-dollar program integrity services team that supported dozens of Medicaid, Medicare, and Commercial plans. Jala also created the strategic focus for post-payment and pre-payment fraud, waste and abuse applications in support of health payers around the country.

The webinar takes place on June 23 at 10AM PST/1PM EST. Please register here.

Read more posts about the role of AI in preventing FWA.