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by Dave Gardner

In an era where many Americans are questioning the ethics of the systems that serve them, health care giant Highmark is striving to identify and reduce financial fraud through the use of sophisticated data analytics, particularly when opioids are involved.

According to estimates compiled by The National Heath Care Anti-Fraud Association, health care fraud costs the nation about $68 billion annually, representing at least 3 percent of the nation’s health care spending. Other estimates range as high as 10 percent of annual health care expenditure, a staggering $230 billion.

National examples of fraud include the case of Florida-based health clinics, which submitted $61 million in false Medicare claims for the treatment of patients with ailments such as HIV, AIDS and cancer, while a Michigan-based scheme manipulated Medicare beneficiaries to reveal their information so that Washington could be billed for $14.5 million of fake medical services. Additionally, the national health care system is now being targeted by organized crime.

According to the New York Times, in a stunning 2017 national case, the Justice Department charged 412 people, including physicians, with defrauding the government of $1.3 billion, including many opiate-related crimes. These health care providers, “Billed Medicare and Medicaid for drugs that were never purchased, collected money for false rehabilitation treatments and tests, and gave out prescriptions for cash.”

Closer to home, a suburban Pittsburgh physician operating a holistic pain management practice was indicted by a federal grand jury on charges of conspiracy and unlawfully distributing controlled substances. Inappropriate prescriptions were written for narcotics such as oxycodone, hydrocodone, morphine sulfate and methadone outside the usual course of professional practice and not for legitimate medical purpose, with a resultant conspiracy to illegally distribute these drugs.

Another example involving charges of illegal distribution of controlled substances was placed against a family care physician and his assistant also operating within the Pittsburgh area. This situation involved both oxycodone and amphetamines.

Data-driven response

To battle this and a menu of other fraudulent activities, Highmark is now operating a data-based, anti-fraud program in West Virginia, Delaware and Pennsylvania.

Kurt Spear, vice president of financial investigation and provider review with Highmark, explained the comprehensive program utilizes registered nurses, investigators, accountants, former law enforcement agents, programmers and industry-leading vendors as it reviews unusual claims and coding reviews, while also assessing the appropriateness of provider payments.

Cutting-edge software leads the way in the effort, as Highmark reviews every claim the system receives for medical care and pharma use by examining 46 sets of data analytics.

During 2016 more than 120,000,000 insurance claims were processed by Highmark, making the work of the anti-fraud program’s 70 people, multiple vendors, and software increasingly complex.

According to Spear, many claim irregularities that are detected electronically simply involve use of the wrong payment codes on the involved documentation and are subsequently accepted. However, overpayments, fraud, waste and abuse are also a reality and lead to about 1,200 cases being individually investigated.

“We have seen people purchase an Accountable Care Act medical policy and then go medical shopping across states to get opiates. In another instance, someone deliberately dislocated their shoulder in a parking lot to go to an emergency room to receive payments,” said Spear. “A high-volume prescription fraud can involve $600,000 of medical bills.”

Opioid scourge

Addiction to opioids is at the heart of many fraud attempts, and Spear noted his organization works closely with federal authorities to indict those involved with this criminal activity, including physicians who may become involved. As part of this effort, Highmark formally declared a war on opioids in February by making a commitment to enact programs, initiatives and funding to help members and their families as they battle abuse and addiction.

“Highmark is working with the Allegheny Health Network and the Drug Enforcement Agency to educate junior and senior high school students on the severity of the epidemic both in our region and across the country,” said Spear. “During 2018, we’ve gone into the schools and talked to thousands of kids about opioid use, and also utilize ER doctors to discuss the horrible problem of addiction.

A key part of the drive to curb opiate abuse must start with youth because, according to Spear, this is where pharma problems often start.

He cited the hypothetical example of a high school athlete who suffered a painful knee injury, and finds him-or-her-self with an opioid addiction after consuming prescription pain killers during recovery.

Spear added that, in the days ahead, advancing data analytic systems will work with artificial intelligence to further detect patterns with fraudulent claims. This capability will allow investigators to predict problems earlier than in the past, and then to deter inappropriate payments by the insurer to caregivers.