How Insurance Companies Are Using Social Media To Detect Healthcare Fraud

How Insurance Companies Are Using Social Media To Detect Healthcare Fraud

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The war on healthcare fraud in America has hit an all time height in activity, as the annual cost and loss due to fraudulent medical billing totals tens of billions of dollars.  In fact, the U.S. Government Accountability Office (GAO) released a report in 2015 that determined the loss to the Medicare program alone in 2015, exceeded $60 billion dollars.

According to the Insurance Information Institute, health insurance fraud (both private and public) is estimated to cost between $81 billion to $270 billion per year on average.

How Insurance Companies Are Using Social Media To Detect Healthcare Fraud

Understanding the Real Cost of Health Insurance Fraud

Consumers may feel that health insurance fraud is a victim-less crime, as national insurance companies are able to absorb the expense, given the size and scope of business.  However, there are many aspects of health insurance fraud that can impact patients, including increases to co-pays, premiums and deductibles.   Both employers and private citizens pay more for health insurance, as a result of loss from insurance fraud, and providers and patients alike should be motivated to help prevent it.

Did you know that up to 20% of the cost of insurance claims for U.S. and Canadian insurers are due to fraud?  Here are some interesting facts and statistics about the cost of healthcare insurance fraud in America:

  • One-third of American insurers say that fraud results in 20% of claim costs.
  • Healthcare fraud incidents increased by 21.7% in 2014, with 2,317,969 cases of American medical identity fraud.

Source Web: 2015 Ponemon Institute©

There are two different types of fraud that plague both private and public health insurance administrators.

1. Opportunistic Fraud is conducted by patients or families, and typically involve one payee and insurance claim.   Some examples of this type of fraud include exaggeration of health complications and severity of injury, or the necessity for assistive devices and medical hardware.  In some cases, medical devices are requested by the patient, and then sold for income when they were never therapeutically required.

Private healthcare fraud conducted by patients can include:

  • Prescription drug request and resale (including opiates and narcotics).
  • Healthcare equipment request and resale.
  • Unnecessary speech, massage or physiotherapy treatment.
  • Sustained disability claims and replacement of pre-injury income where no injury exists.

While opportunistic fraud is more common, the dollar value for each case is substantially less than the second type of fraud.  Individuals acting alone are not able to request the same amount of benefit over time or earnings from fraudulent claims as organized criminal groups.

2. Professional Fraud typically involves identity theft.  Did you know that databases of health records are available on “the dark web” for purchase?  Health records are more valuable to criminals today than any other type of financial information, including credit card numbers.  With access to private health records, criminals are able to establish false identities and engage in Medicare and private insurance billing claims, and schedule monthly payments.  In June of 2016, one hacker was reported to be selling over 9 million American private health records for $486,000.00 payable in Bitcoins.

Professional fraud rings involve multiple level syndicates that buy health records, forge false identities, set up mailing addresses (frequently anonymous rental mailboxes), and submit for reimbursement from health insurance agencies.  Reimbursement for co-pays and services are used as a method to gain payment from private health insurance companies, in most cases for procedures, illnesses and medical needs that never occurred.

Checking the Accuracy of Claimant Activity

Social media is part of every day life for consumers and patients who are recovering from personal injuries or health conditions.   If a patient is collecting a private insurance benefit, they are required to submit a monthly (and sometimes weekly) log of physical activities, to determine both the legitimacy of their claim, and fitness to resume work (depending on the case).

In the past, insurance companies have utilized the services of subcontracted or internal private investigators to physically monitor or “check in” on claimants who are suspected of health insurance fraud.  However, the cost and logistics of monitoring was prohibitive for insurers, who could “spot check” at best for their most suspect cases.

The era of social media and big data has opened the door to online surveillance in new ways that are both legal, and effective at determining fraud.  Any social media network including Facebook, Twitter, Pinterest and Instagram can now be screened by insurance investigators.  Dating websites, networking and meet-up online recreational groups are also monitored.

Claimants who are engaging in physical activities that contradict their medical capability reports, or activity logs can be investigated further and charged with healthcare fraud.   If the claimant has reported that they are unable to travel, the geo-tagging function of social media posts and “check-in” software can help prove they were elsewhere, rather than at home convalescing.

A case reported in a July 2016 article for The Guardian, “Insurance cheats discover social media is the real pain in the neck,” was one example of evidence on social media debunking fraudulent injury claims with admissible evidence.  The story of a ‘whip lash’ claimant who, two months after filing with his insurance company for immobility, tweeted his 7th place result at a regional marathon.  The insurer sued, and the claimant was forced to repay benefits.

Another case reported by CBS news in 2015 involved an Ohio resident, who had claimed more than $30,000 in benefits from his insurance company following an accident, due to his ‘inability to work’.  Insurance investigators combed his social media posts, and collected video evidence at the claimant’s local gym, where he was recorded bench pressing 500 lbs. with friends.

One of the most important advantages for using social media surveillance is the validation of the patient.  Does the administrative and healthcare billing record match the patient who is receiving the payment?  Complex algorithms that scan pictures, locations and keywords (including names and surnames) can be used to identify claimants, and detect fraud.

Finding Patterns for Organized Insurance Fraud

About 36% of private insurers surveyed in 2015 indicated that they routinely use social media networks for fraud investigations.  For larger organized insurance fraud schemes and criminal groups, social media can also be used to geographically narrow down parties who are involved in healthcare fraud.

The GAO estimated that approximately 62% of healthcare insurance fraud cases (public and private) involve healthcare practitioners, clinics, private practices, device and prescription processing schemes.   Advanced analytic and software programs (bots) can be run to search through data to determine patterns in billing to healthcare insurance companies, in order to assist in healthcare fraud investigations.

For additional resources and a list of technology providers that specialize in data monitoring and fraud detection, visit the Coalition Against Insurance Fraud services directory.

4 Common Types Of Healthcare Fraud and How You Can Avoid Them

4 Common Types Of Healthcare Fraud and How You Can Avoid Them

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The healthcare sector in the United States offers some of the highest-paying jobs in the country. But, it also loses a large amount of money on healthcare fraud and malicious practice. As a result, healthcare fraud is a high-priority matter for the federal government and a primary concern of federal law enforcement.

According to the Medicaid Fraud Control Units Fiscal Year 2015 Annual Report, more than 1,100 cases out of the 1,553 convictions reported in the United States involved medical fraud, and over 400 cases were related to neglect and abuse. The judiciary system has announced approximately $744 million in criminal and civil recoveries related to Medicaid fraud and abuse.

Numerous complex legal requirements apply to hospitals and other medical care providers when dealing with providers, suppliers, and other companies. A medical care center’s compliance program comprises policies, protocols, and other compliance documents that can enable the compliance officer to know how to function.

4 Common Types Of Healthcare Fraud and How You Can Avoid Them

Read the following points to know about some of the common types of healthcare fraud and learn how to avoid them.

1. Wrongful Data Entry

Healthcare providers can earn more money by filing records reflecting that they treated or attended to a patient on two separate days rather than on one day. Each consultation visit means that a physician rendered his/her professional services, which can be counted as a distinct billable service. Such physicians often enlist fraudulent services in the claims form with incorrect dates because it’s more profitable for the providers.

Tip: Enhance the Hospital’s Documentation Procedures

As the owner of your healthcare practice, you need to eliminate all possibilities of wrongful documentation. Conduct an internal audit of medical records, medical bills, and patient charts to confirm that the documentation is complete, accurate, and free of discrepancies. Review your established processes for prescriptions and equipment labeling to assure that your staff is working according to the compliance program.

2. Violating Joint Commission Standards

In the United States, hospitals are monitored by the Joint Commission to evaluate their performance. The evaluation process of the Joint Commission includes National Patient Safety Goals to ensure that healthcare providers give safe and high-quality care to patients.

These standards are equally beneficial for healthcare setups, as they can help avoid situations that fall under hospital healthcare fraud. The lack of stringent security measures can make it easy for people with vested interests to cheat you. In fact, several fraudulent practitioners bill patients for the care that they never rendered by altering description of services, location of services, and prescriptions, or by billing for a service not covered under their insurance policy.

Tip: Educate Your Staff About National Patient Safety Goals

Running a healthcare setup means taking steps toward establishing transparency in hospital processes. National Patient Safety Goals help hospitals adhere to the standardized level of care that needs to be given to the patients. Conducting training sessions for staff and introducing simple modifications to your existing procedures can help avoid lawsuits for violating Joint Commission standards.

As a regular practice, ensure that correct information is documented about a patient’s diagnosis, treatments, and medicines, and is shared with the correct people. Make sure that each patient understands the benefits and risks involved in undergoing certain treatments. The National Patient Safety Goals emphasize that hospitals need to provide advanced medical care that is easier on the pocket as well. Hence, along with the patient, even the physician should be up-to-date with the medicines prescribed to the patient and replace the outdated ones with the most economical ones available on the market.

3. Over-utilization of Services

Overuse of medical supplies and equipment for treatment by physicians can add to the final medical bills billed to patients. Such situations typically involve physicians prescribing medicines or services that aren’t really necessary. It is quite easy for unscrupulous healthcare providers to use this scheme on over-trusting patients. By doing this, they can earn extra commission.

Another way of overcharging patients is by recommending unnecessary tests and examinations that may not be included in a patient’s Medicaid cover. Certain hospitals with rehabilitation centers have been found to charge enormous amounts of money for their services, which may be higher than industry standards.

Tip: Introduce Bona-Fide Employment Scheme

A bona-fide employee is one who is compensated with a salary that isn’t less than $455 per week. His/her role includes attending to patients and directly handling business operations of the hospital. Hiring employees on bona-fide contracts can dissolve the ownership of the hospital among a handful of people. This is helpful in lawsuits, as the employee responsible for certain functions of the hospital can be held liable for wrongful practice. Both Stark and Anti-Kickback statutes include exceptions for bona-fide employees, wherein all payments made by an employer to an employee are excluded, even if the employee generates for referrals for the employer.

4. Corruption in the Form of Kickbacks and Bribery

Professionals in the healthcare sector are often caught accepting kickbacks and bribes. A kickback refers to payments made with the intent of influencing another party’s opinion or expecting a favor or reward from the latter. Medicare kickbacks include acts such as healthcare providers intentionally accepting payments, products, or services for the purposes of soliciting Medicare or other healthcare practitioners or businesses. Healthcare providers accepting or offering kickbacks and bribes have been known to unlawfully promote, pay for, or receive payment for referrals.

Tip: Ensure Reasonable Payment Structure

Earning extra wages is one of the biggest reasons why practitioners carry out unlawful practices. Ideally, hospitals need to pay physicians based on their productivity, while ensuring that they are sufficiently compensated for their work.

If you have an under-performing physician working in your hospital, don’t punish him or her by reducing the pay. Instead, introduce a pay-scale that rewards physician on the basis of productivity. Also, avoid hiking salaries to unrealistic numbers for employees with high productivity.

By implementing a comprehensive compliance program, you can identify potential vulnerabilities of facing a lawsuit. Also, following industry standards can minimize billing mistakes, reduce chances of fraud and abuse, and promote safe and quality medical care. This will, in turn, enhance the efficiency and reliability of your hospital.