Predictive analytics in preventing Hospital Fraud, Waste and Abuse

One of the major concerns of healthcare providers, physicians and other stakeholders is fraud, waste and abuse. Billions of dollars are lost each year due to fraud, abuse and waste. This fact makes it essential for every stakeholder to implement solutions to detect, correct and prevent healthcare fraud waste and abuse. The goal is to make healthcare affordable for everyone with the onus on healthcare providers and business partners. 

Service provider fraud is one of the most common types where fraudsters resort to over billing or billing for services not rendered with the intention of generating insurance payments. In some cases, patient IDs are stolen and used to make claims and also to file DME or Durable Medical Equipment claims for services and supplies not provided. 

Jvion’s RevEgis is a robust solution designed to help reduce healthcare fraud waste and abuse through predictive analytics. Estimates by the US Department of Health and Human Services suggest that over $270 is lost every year to healthcare fraud. As costs continue to escalate, this figure could rise significantly if immediate steps are not taken by stakeholders to prevent hospital fraud waste and abuse. 

There are several benefits of utilizing such solutions. To begin with, they are designed to detect patterns of fraud in billing by profiling and segmenting claimants. This helps identify potential fraudsters and any patterns in medical events. Unstructured healthcare data can be analyzed to identify fraud where data extracted

from call center logs can raise red flags wherever any suspicious activity is found. Most solutions utilize multiple methods of analytics for organizations to detect fraud and abuse sooner. This also helps stakeholders build an effective method to detect fraud before money is disbursed. 

Predictive analytics and Personalized Healthcare

The healthcare system is undergoing revolutionary changes with plenty of challenges to meet with the use of new and existing sources of data to deliver personalized care. Clinicians are required to not only make decisions about healthcare but incorporate volumes of health data generated and controlled by patients. Integrating the data into healthcare enables stakeholders to make better decisions, which is made possible with predictive analytics software.

The multiple benefits of predictive analytics

There are numerous benefits of implementing a predictive analytics solution, which include the ability to provide better patient care and significant reduction of costs. While the thought that healthcare could be reduced to algorithms may be intimidating, the reality is that predictive analytics is very promising with the ability to deliver accurate results. Predictive analytics is something doctors have been doing on a large scale for a long time. However, predictive analytics software it a step further and helps to better collate and measure previous data that was hard to obtain.

Combining data with existing sciences of clinical medicine enables a better understanding of the relationship between external factors and various aspects of human biology and medicine. This results in improved ability to deliver personalized care.

The role of historical data

A predictive analytics solution is the best way to allow patient care to be personalized for each individual by studying historical data. It helps physicians make better clinical decisions and avoid adverse events. These solutions like Jvion's RevEgis are designed to reduce readmission rates and help in chronic disease management and patient matching. The objective is to treat individual patient better by widening the data set.