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AI: The next tool in the fight against health care fraud?

The Federal Bureau of Investigation (FBI) estimates health care fraud costs the United States billions of dollars every year. Artificial intelligence (AI) specialists claim they have a tool that can help the government recoup these losses. These specialists state they can develop AI for the government that will find three of the more common healthcare fraud crimes: upcoding, billing for services that were not provided and illegal kickbacks.

Common crime #1: Upcoding

Providers face allegations from the FBI of billing a relatively simple procedure as a more complex alternative in order to receive a larger payment. AI could provide investigators with a comparison of data of treatments typically used for a specific disease and red flag anomalies.

Common crime #2: Billing for services that were not provided

Common allegations also include health care providers who bill for services not rendered. in these cases, investigators can use AI to check for records of treatment. If records are not available, the claim could be red flagged for further investigation.

Common crime #3: Antikickback violations

There are very specific rules which govern what physicians and other health care providers can and cannot accept in exchange for patient recommendations. A violation is a form of healthcare fraud. AI could review referral history and flag any potential patterns.

A recent publication in Forbes delves into the use of these strategies in more detail. One important takeaway: not every error in billing rises to the level of fraud. Both the billing systems and the investigators who make allegations of criminal wrongdoing make mistakes.

Unfortunately, even if the allegation is based on a simple mistake those accused of healthcare fraud must take the allegations seriously. The government has continued to crackdown on this area of fraud and will work to gather evidence to support a conviction.

Hospitals and medical professionals that face these allegations have options. An attorney experienced in these dealings can help to build a defense to the allegations.