Healthcare Looks To AI For Fraud Cure

The applications of artificial intelligence (AI) are manifold, and many feel that perhaps its most meaningful uses are in the healthcare field, where data can be a matter of life and death.

PYMNTS’ Unlocking AI Playbook: Healthcare Edition, a collaboration with Brighterion, examines the frustratingly slow pace of AI adoption in the greater healthcare space. Despite near universal agreement that AI holds the key to decoding numerous medical mysteries, at present one of its most valuable uses is fighting fraud, waste and abuse — FWA in the industry parlance — which threatens to worsen in the near term due to coronavirus-related cybercrime.

“Artificial intelligence (AI) can identify early indicators of fraud and abuse before misdeeds are perpetrated, however, which makes the technology particularly promising for the healthcare space,” the report states. “AI applications can save billions in healthcare administration annually. Better fraud detection also reduces false positives, erroneous judgments that block legitimate transactions. A system that effectively stops fraudulent transactions is better at letting good ones through, and institutions that adopt AI-based fraud detection platforms reduce instances of false positives by more than tenfold.”

Fraud, Waste and Abuse (FWA)

Considering FWA costs the U.S. healthcare system nearly a quarter of a trillion dollars annually, interest in AI-enabled systems is getting much more attention of late as COVID-19 has stress-tested and taxed virtually every U.S. healthcare operation in totally unexpected ways.

“Our research shows that 34.1 percent of healthcare organizations are ‘very’ or ‘extremely’ interested in implementing smart-agent-based AI,” the report states. “Larger firms are particularly enthusiastic about the technology, as 55.6 percent of those with over $500 million in annual revenues are ‘very’ or ‘extremely’ interested, while only 20 percent of firms with less than $250 million in revenues exhibit the same interest.”

In a notable finding, healthcare shows more interest in AI than the banking industry. “Just 23.6 percent of financial institutions (FIs) are highly interested in AI, compared to the 34.1 percent of healthcare firms that say the same,” the report states. “Thirteen percent of healthcare firms report being “extremely” interested — four times the share of FIs that say the same.”

Medical Scams Under the AI Microscope

While penetration of AI into healthcare settings is low, currently at just over 4 percent, there’s room for significant growth across the medical spectrum, from office visits to procedures to billing and payment. As would be expected, fighting fraud is another of AI’s epic purposes.

“Three of the four [AI smart agent] benefits considered most important by healthcare administrators are fraud related: stopping fraud before it happens, reducing payments fraud and reducing fraud management personnel,” the report states. “We find that each of these benefits is cited as the most important by 12.5 percent of respondents that are at least ‘somewhat’ interested in smart agents.”

On the whole the latest findings point to healthcare organizations appearing to recognize “… that smart agents could guard their payment operations, ensuring that the right transactions go through and the dubious ones are stopped in their tracks.”