Software Helps Combat Health Insurance Fraud

Individual or Family Health
Group Health Coverage

Life Insurance No Laughing Matter

One of the number one health insurance companies in the nation, Blue Cross and Blue Shield has joined with IBM in the development and use of a software to help combat the growing problem of health insurance fraud. The software is part of IBM’s  Risk Identification Analysis Service.

With healthcare and health insurance costs on everybody’s agenda lately, insurance industry experts say on area of cost that many fail to overlook is the cost of fraud. According to recent estimates by The National Healthcare Anti–Fraud Association some 10% of all healthcare expenditures annually can be attributed to fraud and abuse. That is close to 170 billion dollars a year in wasted funds. The software is one way that cost conscious health insurance providers like Blue Cross and Blue Shield Health Insurance Plans are fighting back.

A spokesperson for BCBS has said that any person who knowingly commits health insurance fraud is stealing, there are no two ways about it. Fraud affects everyone’s pocket book, and the company is eager to use all means necessary to pursue and convict those who commit health insurance fraud. Every fraud prevented, or dollar recovered from fraudulent claims, saves the health plans’ members money. The IBM Risk Identification Service gives health insurance investigators a powerful tool to help them do just that, which in turn helps them control the costs of health insurance premiums..

The software being used by Excellus Blue Cross and Blue Shield, a BCBS health plan provider serving over 2 million policy holders in Upstate NY, will initially be targeted at exposing prescription drug fraud and abuse. The company said that prescription drug scams are prevalent and costly, and include such thing as fake prescriptions, inflated billing, and patients “doctor shopping” for controlled substances.

The technology is the next generation of IBM’s Fraud and Abuse Management system, which was originally developed by IBM engineers in conjunction with input from healthcare providers and health insurance professionals. The updated software uses a sophisticate series of proprietary algorithms and data-mining capabilities to flag claims that seem fraudulent. By providing this data-mining and analysis service on an as needed or on-demand basis, IBM says it has made this powerful fraud prevention tool available to health insurance plans of all sizes.