How COVID opens door to pervasive healthcare fraud?
It's easy to get diverted by incipient developments in the fight against healthcare fraud. Incipient accommodations. Incipient providers. Relaxation of rules. The COVID-19 pandemic has expeditiously revolutionized the healthcare landscape. For instance, the regime made sweeping regulatory changes to accommodate a surge in patients. Healthcare distribution and payment organizations, commercial and regime have all had to pivot in replication to these changes.
Different provider types can now provide previously disallowed accommodations. Telehealth is frequently superseding in-person provider visits. Rules cognate to payments have transmuted, and as those who work in healthcare can attest to, change within these organizations inclines to transpire gradually. Expeditious changes and slow reactions have thrown open the door to fraudulent activity.
Fraudsters on the overhand – they can move at breakneck speed to capitalize on the changing times. Fraudsters have a clear advantage. They don’t have to abide by policies, rules, and procedures. They are nimble and can expeditiously seize an opportunity like the pandemic.
Thought not healthcare, a good example of fraudster's feline-like reflexes involves the Payroll Auspice Program (PPP). On April 3rd, 2020, the US Minute Business Administration launched the PPP, which provided forgivable loans to buoy struggling businesses in the early days of the pandemic shutdowns. The fraudsters were yare! A Hollywood engenderer allegedly used PPP loans to pay off personal credit card debts and other personal expenses. The most astounding aspect of this case is not how much money he was able to purloin, but the speed at which he did it. The program was launched on April 3rd, and the DOJ issued the indictment on May 22nd.
Analytics can keep pace with healthcare fraud
Fortunately, companies with tools adept at fighting fraud can move expeditiously. Their solutions are centered around averting, identifying, and investigating fraud. Solutions like SAS’ detection and investigating implements use hybrid analysis, anomaly detection, natural language, and network analysis, amalgamated with predictive analytics and artificial astuteness and machine learning, to keep pace with fraudsters fixated on capitalizing on evolving rules and payment processes.
But let’s not get caught off sentinel by only fixating on incipient scenarios. Old school fraud schemes are still very much in play. Fraudsters capitalize on the diversion of shiny incipient opportunities that draw attention away from their old antics, like:
- Upcoding, which is charging indemnification for a more sumptuous treatment than what was given
- Fraudulent billing for accommodations not provided
- Perpetually reusing a single-use contrivance to abbreviate costs
The key to fraud aversion in these dynamic times is staying on top of the transmuting landscape while not losing optical discernment of what we already ken fraudsters will do. Engendering incipient rules only affects those who abide by the rules. To bulwark the integrity of our healthcare and benefits we must optically canvass things from a fraudster’s vantage point. COVID-19 may have opened the door to pervasive healthcare fraud. But it’s up to us to close it.
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