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Copyright © 2019 Society of Actuaries
DISCUSSION
Claimants who misrepresent impairments to satisfy the benefit eligibility trigger was identified as
the highest type of fraud, waste and abuse that insurers encounter. The industry has not
reached a universal consensus about the best tools to establish eligibility, since each tool has its
own benefits and limitations. In-person benefit eligibility assessments represent a moment in
time against which to draw a conclusion, but aren’t helpful when a claim is filed after care has
already ended. A lack of standardization raises its own challenges when reviewing provider
records to determine needed assistance. While attending physician statements and medical
records can confirm a diagnosis or yield a score from a cognitive screening test, they aren’t
always the best source of information about activities of daily living. Furthermore, distinctions
between “hands-on assistance” versus “stand-by assistance” and the frequency and intensity of
needing such assistance can be challenging to pinpoint. Claims professionals do well to consider
all “tools in the tool box”—selecting the right ones for the task at hand to make the best
eligibility decision.
Providers who are overbilling for services in excess of what was rendered came in second place.
This issue is mostly linked to home care claims originating from an insurer’s concern that it can
be difficult to tell precisely how long a caregiver is there and what they are doing while with a
claimant. The good news on this front is that electronic visit verification (EVV) has made inroads
with home care providers, since all Medicaid-reimbursed home care providers must be using
EVV as of January 1, 2019. EVV is technology used during a home health care visit—through a
mobile or landline telephone—to check in and out—and some allow the recording of services
rendered. This technology has implications to the home health care delivery system beyond just
those Medicaid-reimbursed claims. It is important to note the government moved to mandate
EVV believing it would cut down on fraud and abuse.
The survey yields a finding that all carriers are using so-called “red flags” to help detect fraud,
waste and abuse. It is also common to detect potential fraud, waste or abuse through internal
quality assurance activity, through claim system controls and by training staff to follow standard
operating procedures for so-called “high risk claims.” While these are not unexpected results, it
is somewhat concerning that only a little over 20% of companies who responded indicated they
are employing automated or predictive data analytics to identify potentially suspect claims.
While it is encouraging that close to 40% of those who responded indicated they are considering
developing this tool, perhaps a lack of resources or know-how is limiting use of this detection
method. It is also possible the limitations of legacy systems, the data captured and the quality of
the data available may not be suitable. Predictive analytics doesn’t have a long track record as a
detection tool and the survey results indicated a universal belief that it is too soon to tell if it is
producing anticipated results. This is one area to watch for future outcomes. Furthermore, it
appears those who are thinking about it or haven’t begun to explore predictive analytics can
learn from those who have.