Recent trends have highlighted a troubling reality : Criminals are becoming aware of a new gold mine in the health care payments industry , and many health care providers are ill-equipped to stop them . There are more than 900 operating businesses in the U . S . that are paying on behalf of health care plans . 1 While the pandemic and other factors have forced them to adopt more modern and expedited forms of payment , the health care industry has historically been slow to change , such as in the realm of technological security . The reality now is that health care is set up to process more payments faster without the protections to keep those payments safe from criminals .
Understanding health care payments and the criminal opportunity
The health care industry contains three key entities : Payers , providers and members . 1 ) Payers are insurance companies . They “ pay ” out on claims submitted by providers . 2 ) Providers are health care companies and / or professionals that “ provide ” health care services to members . 3 ) Members are people who are “ members ” of various health care networks .
Payers and providers contract with vendors who perform various services , including invoice review , claim review , claim negotiation , payment processing and network access . As the entity directing payments from payers to providers , health care payment service providers ( or those who inform payers where payments are made ) are a critical junction point in the disbursement of insurance claim payments to providers .
The opportunities for fraudsters and money launderers to create significant financial risk lies within the payments side of health care because criminals follow the money just as compliance professionals do . Healthpayer Intelligence reports health care expenditures exceeding $ 4 trillion in 2020 , 2 an amount worthy of any criminal ’ s attention . Graphic 1 depicts the increase in health care expenditures .
Graphic 1 : CMS national health expenditure data
$ 4,500.0 $ 4,000.0 $ 3,500.0 $ 3,000.0 $ 2,500.0 $ 2,000.0 $ 1,500.0 $ 1,000.0 $ 500.0
$ 0.0
$ 4,124.0
$ 3,759.1 9.7 %
$ 3,163.6 $ 3,305.6
$ 3,446.5 $ 3,604.5
4.3 %
5.4 % 4.5 % 4.3 % 4.6 %
2015 2016 2017 2018 2019 2020
National health expenditure $ National health expenditure %
12.0 %
10.0 %
8.0 %
6.0 %
4.0 %
2.0 %
0.0 %
Source : Centers for Medicare & Medicaid Services , Office of the Actuary , National Health Statistics Group ; U . S . Department of Commerce , Bureau of Economic Analysis ; and U . S . Bureau of the Census 3
Visualization by Dustin J . Eaton and Derek McDaniel
ACAMS Today September – November 2023 41