Boston, March 11, 2015 – In a post-Affordable Care Act era, healthcare providers face shrinking health plan reimbursements, and consumers face larger medical bills. Fraudsters, meanwhile, read new opportunities in the regulatory changes and are zeroing in on stealing, selling, and using consumer data to falsify claims. These dynamics present risks that bolster the case for fixing an existing post-payment detection process and investing more deeply in fraud-prevention tools.
This report, based on interviews with 20 companies representing special investigations units for health plans and fraud analytic vendor executives, sizes U.S. commercial healthcare fraud and examines the changing dynamics of member and healthcare provider schemes. It examines fraud as it stands alone and as a process within fraud, waste, and abuse.
This 24-page Impact Report contains 14 figures and four tables. Clients of Aite Group’s Health Insurance service can download this report.