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Insight into new techniques and technologies used to detect healthcare fraud

AI is more than just a buzz word; it is a new tool that is taking the legal and healthcare world by storm. AI plays an important role in detection of diseases and federal officials note that it will soon also play an important role in detection of healthcare fraud. A recent study dug into the use of AI to analyze claims for payment and found that this may be the perfect opportunity for use of this tool to root out fraud. This is largely due to two key factors:

  1. Large amount of data available through electronic health records; and
  2. Advances in machine learning.

Authorities are hopeful that these two factors will allow for experts to refine these systems to better flag potential instances of healthcare fraud. Some of the more common examples the system will look for include billing for appointments even if the patient did not show up, upcoding, or billing for services not provided.

It is important to note that this is not the first time the government has used data mining and other advanced computer processes to search for healthcare fraud. However, recent advances in the capabilities of these systems have led to increased use. Although these tools can provide important information about the potential for fraud, it is important that officials make the distinction between information that requires further investigation and outright proof of fraud.

Researchers with the study note that the information provided through use of AI is just one part of the equation. Although the results are valuable, they are far from infallible. Officials must gather additional evidence to support allegations of healthcare fraud.

The focus on enforcement is not to be taken lightly. Physicians and healthcare leaders are wise to take note and make sure they have practices in place to help better ensure compliance and reduce the risk of allegations of healthcare fraud. One important step: regular internal audits. It is good practice to use these audits to review practices and make adjustments when needed before a small issue snowballs into a bigger problem.

Attorney John Rivas is responsible for this communication.