AFC CHALLENGES
A tremendous amount of money flows through the health care industry , and significant amounts are lost due to fraud , waste and abuse
Beyond health care payments , the health care industry is burdened with risk , providing endless opportunities for criminals . The National Money Laundering Risk Assessment ( NMLA ) estimated that over the course of four years ( from 2017 to 2020 ), the average annual revenue generated from drug-related sales on the darknet was $ 315 million . 4 All four years total a little over $ 1.2 billion , less than 1 % of health care administrative costs for a single year .
Three other examples include : For the 2020 fiscal year , the Department of Justice ( DOJ ) filed 263 indictments charging 405 defendants on alleged health care fraud schemes totaling more than $ 4.7 billion . 5 In 2022 , the NMLA recorded that self-reported losses from cybercrime for 2021 totaled more than $ 4.1 billion , 6 and business email compromise ( BEC ) loss in the same year totaled $ 1.8 billion . 7
These are staggering sums , but they pale in comparison to what the U . S . spends on administrative complexity in our health care system . That number totals around $ 248 billion , 8 a figure more than 20 times greater than the prior four figures combined . The only comparable figure is the tragic amount generated by criminals in human trafficking at $ 150 billion . 9
A tremendous amount of money flows through the health care industry , and significant amounts are lost due to fraud , waste and abuse . Undoubtedly , the industry is being assailed by fraud , and it is getting worse . Over the last several years , this besiegement has provided a ripe opportunity for criminals , as evidenced by a Federal Bureau of Investigation ( FBI ) notice issued in September 2022 , warning that cybercriminals are targeting health care payment processors to divert payments to accounts they control . 10
Criminal exploitation of health care payments
As criminals have become aware of the relationship between payers and providers , they have started using cyber tactics to exploit it . USA Today reports that in 2022 alone , more than 40 million Americans ’ medical records have either been stolen or exposed . 11 The familiar tactics of phishing , BEC and account takeover are used to infiltrate the health care payment ecosystem . For instance , in 2020 , the FBI ’ s Internet Crime Complaint Center ( IC3 ) reported losses exceeding $ 1.8 billion , accounting for more than 40 % of cybercrime losses for the year . 12
42 acamstoday . org