Elements of Healthcare Fraud, Waste, and Abuse

It’s a new day and with it a new focus on fraud. At Qlarant, we’ve been living the life of learning about fraudsters, understanding their habits, and uncovering their patterns. Alongside our local, federal, and state partners we’ve been on the frontlines of combating fraud, waste, and abuse for nearly 20 years. Beyond knowing what to look for, any fraud elimination organization needs a combination of key elements to be successful in recovering the public money.

The Data Element

Everyone likes to begin fraud conversations with data. Everyone likes data. Data is sexy. It’s the new oil. Everyone wants as much as they can get. So much talk about data. Getting it, cleaning it, normalizing it, analyzing it, and processing it. Data, data, everywhere and a lot to think. Data is critical for modern fraud detection. Once upon a time, the cheering data chorus heralded AI and machine learning to discover fraud patterns based upon fraudulent behaviors. New school fraudsters are using AI/ML to simulate proper behaviors to evade algorithms looking for abnormal behaviors. This new vector requires looking beyond claims data and public records, into people-generated data and meta information from unassuming sources.

The Systems Element

Turning data into information and then using that information to make decisions on fraudulent behavior requires discipline. At Qlarant, we articulate fraud mitigation plans through data handling, information processing, and adjudication processes. Combining digital automation and human-in-the-loop systems ensures privacy is maintained while keeping a vigilant watch on the bad guys.

The Human Element

Technology is a key driver at Qlarant. However, our focus is on people. Focusing on technology and data while sacrificing precision and privacy leads to a preponderance of false positives, inefficiency, and waste of resources. A focus on people strengthens processes so appropriate courses of action can be taken and proper data handling and usage maintains privacy. A focus on quality and better outcomes for people needing health and social services is what builds a strong program integrity organization. This focus drives us to root out fraud, waste, and abuse. Real people are impacted when fraudsters steal from those who need services most.

Combining the Elements

We talk about AI+HI (Human Intelligence) around here. I’m often heard saying it several times a day. Throwing a lot of AI at mountains of data is one element of rooting out fraud. However, human experience is fantastic at knowing which behaviors are fishy, and understanding the evidence needed to prove it. AI+HI is how false positives are reduced, fraudsters are found, and our customers have better outcomes.