Combating healthcare provider fraud and abuse

According to estimates from the federal government, and from issues-based groups such as the National Health Care Anti-Fraud Association (NHCAA), as much as 10 percent
of all healthcare expenditures in the United States may be lost each year to fraud, abuse and waste. That’s more than US$100 billion — coming largely from healthcare providers attempting to defraud the system. Methods of cheating, such as billing for more expensive services than those actually performed, or even conducting medically unnecessary procedures for the purpose of billing insurance, have become more sophisticated and more costly to payers.

Recognizing the ultimate impact healthcare fraud and abuse have on private health insurers, government-funded health plans and consumers, IBM has worked closely with healthcare investigators to develop the IBM Fraud and Abuse Management System. A sophisticated, comprehensive solution with both proactive and retrospective detection capabilities, the Fraud and Abuse Management System helps healthcare payers identify and pursue fraud cases faster and more cost-effectively.

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