The Impact of Fraud, Waste and Abuse in the Health Care Industry and How to Eradicate It

Fraud, waste and abuse (FWA) have significantly plagued the healthcare sector and continue evolving quickly in a rapidly changing healthcare landscape. As a remedy, state and federal governments are implementing vigorous measures against FWA in the health care system. For example, the MFCU statistical data for 2020 in Medicaid validated that in Alaska, there were 203 cases and over $3.4 million recovered; in Rhode Island, there were 103 cases and over $5.8 million recovered; and in New Hampshire, there were 56 cases and over $2.3 million recovered. In Puerto Rico, there were 44 cases and $381,034 recovered.

Unfortunately, these efforts are not enough. It is a fact that health care organizations continue to heavily use traditional claims review and self-reported complaints without significant access to other data sources that could inform fraud investigations. Yet, as we have learned, reliance on historical patterns to make decisions is not effective and can even be detrimental.

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