A Business Plan for Health Insurers: How to Tackle Fraud & Insurance Claims with Technology

Health insurance fraud has presented itself to be a challenge in the healthcare industry. The reality is that health insurance fraud can take different forms - from billing for services that were not rendered to patients, to kickbacks, bribery and overutilization of services. On average, there are at least $68-$300 billion in annual damages due to fraudulent health insurance claims in the United States. This accounts for nearly 10% of the income of the national health care industry – money that can be redirected towards creating public health programs to address issues of healthcare. The fundamental problem for health insurers dealing with fraud is their inability to design an effective and efficient mechanism with their current systems at a low cost. The goal of this paper is to outline a plan for health insurers to conduct in depth analyses of possible fraud and to create warning systems to alert to potential abuses in billing and claims systems. Current solutions on the market are complex, expensive and require long term contracts – limiting such solutions to mainly large health care organizations that seek to make drastic changes in their bottom line. This business plan outlines health insurance fraud prediction and detection methods using big data and artificial intelligence technologies to help insurers from losing money to fraudulent claims and to drive business performance