Healthcare Fraud, Waste and Abuse Detection

Enformion for Health Care Fraud, Waste and Abuse Detection

Detecting fraud in your agency is an important part of providing quality healthcare. See how Enformion can help with this most essential of tasks.

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Stop Healthcare Fraud with Enformion

Quoting former Senator Everett Dirksen, “A billion here, a billion there, pretty soon you are talking real money.” The problem has become severe.
Annually, the depletion of taxpayers’ resources due to improper payments and social program fraud now reaches $150 billion.

In 2019, the cost of improper payments was over half of the annual interest on the national debt. There’s a new recession on the horizon and rising government spending. When individuals have access, financial motivation, and the perception of avoiding capture–some will consider committing fraudulent acts.

Preventing Improper Payments

From 2003 to 2012, Federal agencies reported more than $1.2 trillion of improper payments. While the scope and cost to state and local governments are unknown, same-type expenditures are about 85% of federal. So another $1 trillion during the same period is a reasonable assumption.

After the passage of IPIA in 2002, IPERA in 20010, and IPERIA in 2012, progress was made on reducing this cost, but improper payments surged in the wake of the Great Recession. With unprecedented new government spending and economic challenges on the horizon, history may repeat itself, and improper payments will again be on the rise.

Healthcare Provider Fraud

To combat these concerns, we have created the Enformion for Civil Enforcement software suite. With it, government healthcare officials can research data points relevant to typical provider schemes:

  • Professional licensing data verifies the providers’ licensing.
  • Asset and debt records validate the provider’s claims of financial solvency.
  • US corporate and business records investigate named subcontractors.
  • Personal and business relationships can discover conflicts of interest among related parties.
  • Enformion’s robust person data and identity verification capabilities guard against cases of identity theft and nonexistent patients.

Fraudulent Claims for Benefits

Dual Participation

Beneficiaries with financial difficulties may relocate in search of better opportunities; that is the American way. But they may also, unsurprisingly, apply for additional benefits in their new state of residence.

Whether the duplication is innocent and unintentional, or a fraudulent effort to obtain additional benefits, the resulting dual participation creates an undue burden to taxpayers.

Enformion’s research application and automated batch processing capability provide a Day One/turnkey solution for health agency leadership to quickly mitigate this growing problem.

Organized Claims Fraud

Some crimes are a team sport, though few are among strangers. Co-conspirators usually know each other, grew up together, or are related. Enformion can locate friends, family, and associates for each subject profile. This can lead to the discovery of these connections between a beneficiary and the provider, or among several healthcare providers. The Enformion social media research capability can also discover less-formal relationships between actors.

Deceased and Nonexistent Beneficiaries

Though strange, and a prominent form of waste, most states make minimal effort to discover and remove deceased and nonexistent beneficiaries from social program rosters.
For services such as capitated healthcare programs, or providing health HMO insurance coverage, the wasteful cost to taxpayers can be enormous.

Enformion’s identity verification and management, combined with our deceased audit services, assist government agencies with reducing both of these risks.

Transmitting Sensitive Information Safely

Integrating personally identifiable information (PII) into your customer relationship management (CRM) or case management (CM) system can be a complex topic. Enformion makes it easy.

Enformion provides access to our Application Program Interface (API) to integrate our data into your modern web-based applications.

For legacy solutions, we also offer our Batch File Exchange Services using our fully automated Secure File Transfer Protocol (SFTP) gateway.

From your input file, we append and output the content to meet your business requirements.

  • Security policies, procedures, protocols, and Certifications ensure that sensitive information never gets into the wrong hands.

Better Manual Reviews

Even with the best of automation, a human eye is often required. Screening millions of healthcare claims means there are more suspects to review. Enformion provides a solution for this problem too.

Enformion for Civil Enforcement (EFCI) provides a fast and easy-to-use application to quickly find and review backgrounds, associations, and business information.

Taking Your Show on the Road?

Enformion for Civil Enforcement is fully compatible with mobile devices.

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Talk with a specialist today to learn how Enformion can help to customize a solution that’s right for you.

Call us at 1-855-281-3915, or via online today.