AI and Human Investigators Team Up to Catch Healthcare Fraud
Fraud, waste, and abuse cost the U.S. healthcare system between tens and hundreds of billions of dollars annually. Elevance Health now pairs artificial intelligence with human investigators to identify billing errors, upcoding schemes, and inefficient care patterns buried in claims data.
The approach works because AI excels at finding anomalies across millions of records, but people decide what those patterns mean. A cardiologist billing differently than peers in neighboring counties might be making a mistake, following a different contract, or intentionally upcoding. Only a human investigator can determine which.
Three Types of Problems, Three Different Meanings
Healthcare organizations group fraud, waste, and abuse together, but they're distinct problems:
- Fraud involves intentional deception to obtain money or benefits - such as billing for equipment never delivered.
- Waste typically happens unintentionally, like ordering duplicate lab tests when results already exist in a patient's record.
- Abuse occurs when standard practices aren't followed, such as consistently billing for high-level office visits when routine visits would apply.
How AI Speeds Up the Detection Work
AI-powered tools analyze claims and payment data to flag unusual patterns. Within Elevance's clinical auditing unit, one program cut medical record review time in half - from 40 minutes to 20 minutes per case across nearly 23,000 annual reviews.
The software can summarize thousands of pages of medical records and standardize provider contract data, freeing investigators to focus on judgment calls rather than data wrangling. "AI gives us the ability to see patterns humans might not on their own, but it's our people who bring context and clarity," said Matt Glynos, vice president of Carelon Payment Integrity.
Education First, Recovery Second
When investigators discover problems, they often start with education. A provider might have used the wrong billing code or prescribed medication outside a member's coverage. These conversations help align providers with evidence-based guidelines.
If education doesn't resolve the issue, Elevance's teams can recover improper payments, recommend contract terminations, or pursue other remedies. The goal extends beyond cost control - ensuring healthcare dollars follow benefit design and clinical evidence protects the system's integrity.
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