Accurately and proactively identifying patients in a provider’s office before healthcare services are performed significantly reduces the likelihood of phantom billing and medical identity theft – and the overwhelming financial implications of each.

In response to a reporter’s question, notorious bank robber Willie Sutton was quoted as saying thieves rob banks “because that’s where the money is”. Today, the money is in a wide variety of areas beyond banks, including the enormous – and growing – healthcare business. The FBI estimates that healthcare fraud is an $80 billion annual challenge.

With so much at stake, healthcare providers and insurance companies need new methods and tools for preventing fraud. At the same time, providers are looking for better ways to protect their patients’ medical identity, which has become critical.

To combat fraud, payers and providers often turn to big data analytics to identify irregularities. The drawback to this approach is that analytics are only applied after a claim has been submitted and paid – long after the fraud has occurred and too late to prevent it. Additionally, data analytics are incapable of capturing fraudulent billing for services not rendered when a patient is not physically present; as such claims may appear to be correctly coded and will likely be paid by the insurance provider. In both cases, the only recourse payers have is to attempt to recoup payments, which in most cases is difficult if not impossible.

Preventative measures are vital for detecting and preventing fraud before services are provided, payments are made, money is lost and medical records are corrupted with misinformation. The key to accomplishing this is to make sure patients are properly identified at the provider’s office – before the fraud can occur.

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November 7, 2016 By Mark Clifton, SecurityInfoWatch