Predictive modeling software could be applied in programs such as Medicare and Medicaid as tools to prevent fraud and facilitate care management, according to a newly releasedworking paper from UnitedHealth Group’s Center for Health Reform and Modernization.
The National Health Care Anti-Fraud Association conservatively estimates that about three percent of U.S. healthcare spending is lost to fraud or payment and billing errors — and healthcare fraud is a fairly established criminal market, like financial fraud and retail theft. The Association estimates that about 70 percent of payers use some form of an anti-fraud system, many still using the “pay-and-chase” methodology.
Minnetonka, Minnesota-based UnitedHealth, one of the largest managed care companies and the parent company of the healthcare technology firm Optum, noted that payers are starting to embrace predictive analytics for fraud prevention, with Medicare and Medicaid increasingly adopting the pre-claims adjudication process used by commercial insurers. Read more