AFC CHALLENGES
There have been various figures on waste published , with estimates ranging “ from $ 600 billion to almost $ 2 trillion annually , or 17 % to 53 % of the $ 3.6 trillion ” spent annually on health care . 20 There are many who have taken up the charge to solve for some of the many challenges faced from care to payments . When the health care industry moves labor-intensive tasks to automated ones , the results allow for “ security teams to identify and address vulnerabilities more quickly and rapidly detect intrusions and investigate suspicious activity .” 21
Automation goes beyond the solutions stated above . However , even those steps can make a profound impact in reducing costs , streamlining accounting processes and improving operating efficiencies . For instance , transitioning to electronic funds transfer ( EFT ) payments via an automated clearing house ( ACH ) provides “ a number of benefits other electronic payment options and paper checks do not .” 22 This delay in transitioning to more expedited and less labor-intensive options goes beyond the doctors ’ offices . With estimates topping $ 500 billion issued in paper checks yearly , 23 the crime of opportunity becomes too great for fraudsters . NBC reports from U . S . Postal Inspection Service data that there have been more than 2,000 attacks on carriers nationwide since 2020 . 24 Fraudsters target mail carriers for their arrow keys , which allow them to steal packages and checks from Postal Service collection boxes as well as cluster and apartment mailboxes .
Recommendations for protecting health care payments
The path to mitigating risk and fraud in the health care payments space may appear daunting , but steps must be taken . As noted in a recent article in Politico , businesses in the health care payments industry cannot rely upon the federal government to be their primary source of protection . 25 Furthermore , any business worth its salt educates employees that each of them is the best source of prevention for their organization . The same is true for each health care provider , vendor and third-party administrator .
In that vein , a good place to start would be to review the FBI Private Industry Notification on Healthcare Payments , which outlines a series of recommendations . 26 In addition to these recommendations , we recommend the following :
1 . Prevent fraud : The prevention of fraud within the health care payments space is primarily focused on the provider side of the equation . This starts by ensuring that provider data is being validated by trusted thirdparty sources as an enrichment to the national provider identifier records . Validating provider information ( e . g ., entity name , employer identification number , address , phone , etc .) with multiple sources , both private and public , is key . Considering the focus on expediting payments via ACH or more modern instant payments , validating legitimate bank accounts for the settlement of these funds is crucial . This can be done by utilizing a “ database aggregator ” and / or “ user authenticated ” banking validation . Outside such validation , a critical feature in preventing fraud is the use of behavioralbased tools that can identify behaviors indicative of a fraudster . As noted by various published sources , the greatest fraud impacting health care payments is through account takeover , so watching for common signals associated with this type of fraud is critical .
2 . Detect fraud : Once prevention mechanisms are in place , the development and enhancement of the detection process can begin . Using existing logic from vendors , internal data and information from the established health care payment ecosystem can help risk score providers being onboarded . This foundation can also be leveraged to create alert notifications based on these internally defined rules .
3 . Investigate and remediate fraud : Although it is the hope of every anti-fraud professional to never have an instance of fraud , it is critical that a fraud framework include the alert prioritization , escalation and remediation process . The ability to succinctly learn from each event and outline the control breakdowns is critical . In addition , relevant businesses need individuals skilled in these areas . If firms cannot find them , then they must be willing to spend what is necessary to train them .
4 . Collaborate : Criminals are attacking health care with a fervor never seen before and from all angles . In addition , the collaboration between criminals and their sharing of insights are likely taking place regularly via the dark web and other places . Health care payment facilitators looking to solve or , at least , mitigate the fraud paradox alone are likely to face an uphill battle . Helen Keller is often attributed as saying , “ Alone , we can do so little . Together , we can do so much .” A coordinated effort among health care payment providers working in unison , sharing best practices and learning from each other will at the least put the anti-fraud professionals on a level playing field .
44 acamstoday . org