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Exposing waste in our healthcare system means taking action now

The rising cost of health care in the United States is unsustainable for big companies who must provide health coverage for their employees in order to attract and retain talent. This was an issue long before COVID-19 became a regular part of our vocabulary and will be long after the pandemic is under control. Seeing health care costs through the lens of data analytics gives employers with self-funded health care plans the view to one way in which the problem can be addressed right now. Eliminating even a portion of the dollars being lost to fraud, waste, and abuse within health care claims would have a substantial impact in lowering per member per month costs for employers. Industry experts estimate that billions of dollars are leaking out of the system with no end in sight. Making a meaningful impact on the rising cost of health care can begin with using statistical, clinical, and claims expertise to deliver the most complete cost reduction solution directly to the actual stakeholders: self-funded employers.

As more and more companies shift toward the self-funded model for health care, business leaders have little awareness of how their dollars are being spent. There is waste within the system as well as significant fraud and abuse with extraordinarily little transparency. Since processing healthcare claims is outside the core competency of most employers, patterns of error often go unnoticed and result in the unnecessary spend of health plan dollars. Employers need the expertise necessary to evaluate payments for appropriateness in the form of independent, pro-active intervention on a regular basis and for every claim.

Insurance carriers, in the role of third-party administrators, do their best to manage the waste in the system while processing claims, but their focus lies on moving claims fast and paying claims. The addition of an independent reviewer using statistical, clinical and claims experts can deliver the most effective cost reduction solution on the market, customized to each employer’s unique population. There is real value – trackable ROI – in eliminating fraud, waste, and abuse from health care claims. Finding providers duping the system through pass-through billing schemes or waste in the form of medically unnecessary testing or abusive ER users can bring employers up to 5% or more reduction in costs.

The best reviews are done with independent experts and carriers as partners in the process of analyzing claims and identify areas for savings. When a regular and complete review using methods such as inferential analytics and predictive modeling is used to help carriers do their job it can fill in the gap when it comes to fraud, waste, and abuse oversight.

Finding the well-hidden and overlooked fraud, waste and abuse that is contributing to the rising cost of health care can be done. It just takes employers who are willing to address the issue and work through process that will ultimately drive value and improve care for their employees.