Fighting Fraud, Waste, and Abuse in Digital Healthcare

Clay Wilemon
CEO
4L Data Intelligence

Clay Wilemon, chief executive officer at 4L Data Intelligence, spoke with Medical Device & Technology about the platform technology to help integrate AI in healthcare. The program is focused on improving integrity, specifically data, provider, and payment integrity.

(MDT:) What are the struggles with insuring digital healthcare services?

Wilemon: The digital healthcare services and solutions is a big landscape. One of the manifestations of the post COVID era is the increase in the delivery of digital health. We think about telehealth in terms of seeing your primary care physician, along with behavioral health and other solutions being delivered digitally. That has opened up a world of payment integrity issues. For example, so many of those services are to be paid for based on the amount of units that are consumed (or the amount of time the provider spends with the patient). It makes things difficult to track or validate that the services were rendered in the quantities that they’re being billed for. That’s where technologies like ours can aggregate multiple types of data. With that, we can understand both if the service was actually rendered and also leveraging digital, mobile, and internet data to validate that the service happened in the time and place it was reported to.

(MDT:) How big of a problem are fraudulent claims in this area?

Wilemon: You really have to go beyond just fraud to look at the landscape. The problem is made up of fraud, waste, and abuse. These are the three categories that the CMS uses to define the problem. Really, they all boil down to overpayment. Fraud, waste, and abuse is really a way of saying that there are three specific ways in which we as a country and consumers overpay for healthcare. The size of that problem in the US, depending on the source, is going to be somewhere between $250 billion to $9 billion a year.

(MDT:) Who is most impacted by this? Payers, HCPs, or patients?

Wilemon: This effects every participant in the healthcare system. The amount of money that we have for healthcare, whether it’s in a commercial health plan provided by an employer, Medicaid, or Medicare, there’s a finite amount of money to provide care. If you’re taking money out of that pool for nefarious reasons, that money isn’t providing healthcare. Everybody is effected because the fraud, waste, and abuse issue is driving up the cost of commercial healthcare every year by double digits, along with Medicare, Medicaid, and the individual consumer. As costs go up, copayments go up.

The other audience that we don’t think about when it comes to fraud, waste, and abuse is providers. The ones who are providing good, quality care in an honest way to their patients, they are, perhaps, most affected because it takes away from the resources that they can use to deliver the care that they need to.

(MDT:) In regard to digital healthcare, how can abuse in this area be corrected while also protecting people’s private data?

Wilemon: When you look at digital healthcare, which is the delivery of healthcare through digital means, the key to preventing fraud, waste, and abuse is being able to quantify that the care was delivered in the increments in which was supposed to and when it was delivered. We need a solution that can automate the near real-time detection of whether that service place, where it took place, and the IP address of the computer or device used. For example, we look at a provider that might be trying to game the system, they could be using multiple computers at the same time to deliver fictitious care to fictitious patients. If you can aggregate that data in addition to the claims data, then you can detect an overuse or abuse problem.

(MDT:) What role will AI technology play in healthcare’s future?

Wilemon: There are four levels of integrity. We mentioned data, provider, and payment integrity. The fourth level is decision integrity. The great area of promise for healthcare when it comes to artificial intelligence is the ability to predict what is going to happen before it happens. This will allow providers to have insight with the treatment of an individual patient or population. It also allows HCPs to personalize medicine even more and make decisions in advance to prevent problems and costs.