Excellus BlueCross BlueShield (EBB) has become the latest US health
insurer to turn to technology group IBM to assist it in fighting
fraud. EBB has contracted to use IBM’s new Risk Identification
Analysis Service, developed in collaboration with health care
organisations, to combat health care insurance claim fraud. IBM’s
automated system can identify potentially fraudulent and abusive
behaviour before a claim is paid, or analyse past behaviours to
flag suspicious patterns.
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“Fraud affects everyone’s bottom line, so we aggressively and
proactively pursue recoveries and convictions,” said Flora Allen,
director of EBB’s special investigations unit. EBB has 2 million
members in New York.
Allen explained that EBB would initially use IBM’s automated
service to review pharmacy-related claims to uncover complex,
illegal schemes. Schemes may include collusion, inappropriate
billing practices, prescription forging, prescription-pad theft and
doctor-shopping, a term used to describe people who visit numerous
doctors to obtain prescriptions for a drug to which they have
become addicted.
In addition to pharmacy claims, the IBM service can analyse about
24 other specialities such as cardiology, home health care,
gastroenterology and durable medical equipment suppliers.
IBM noted that estimates made by the federal government and an
industry body, the National Health Care Anti-Fraud Association,
indicate that up to 10 percent of health care expenditure in the
US, or $170 billion, may be lost each year to fraud, waste and
abuse. Other users of IBM’s service include health insurers Aetna,
Cigna and Humana.
