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Hi, everyone. This is Lucas Voss with Becker's

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HealthCare and the Becker's HealthCare podcast series. Thanks

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so much for tuning in today, and I'm

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very excited to be joined by Deborah Hamer,

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the director of product FWA Solutions at Cerus.

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And we have a very exciting

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topic to discuss, lots to discuss there. We'll

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talk about fraud, waste, and abuse in the

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payment integrity space. Deborah, thanks so much for

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joining us.

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You're welcome, Lucas. Nice to meet you. To

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get us started here, can you introduce yourself

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and just give us an overview

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of your experience in healthcare?

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I can. So as you mentioned, I'm Deb

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Hamer, and I'm the product development director at

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Cerus,

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focused on fraud, waste, and abuse products and

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services.

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I have 30 years in the technology development

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space with 15 of that within the health

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care industry at 2 pretty large health care

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companies.

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And my focus and experience has been in

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the area of software development and data science,

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focused primarily

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on the provider systems

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and claim systems,

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with, some focus also in big data,

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artificial intelligence, machine learning,

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and cybersecurity and fraud.

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And that space has developed so much too.

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So much experience

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here. Again, Deb, thanks so much for for

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joining us. Really appreciate it. When I looked

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at some of the numbers associated

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with with fraud, waste, and then also the

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abuse that happens, it it was really staggering.

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Tens

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of 1,000,000,000 of dollars really annually. And there's

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a lot of a lot of numbers that

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we don't really know. It might be higher,

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which is incredible.

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Why should health care organizations

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focus on getting the processes around this topic

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right

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right now and address the issue most importantly

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today?

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Yeah. I think there's there's 2 core reasons.

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1,

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technology continues to advance at such a rapid

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pace. All of us are hearing about AI.

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Right? And, actually, AI has been around for

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a long time, but it's becoming mainstream.

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And then the second is around administrative systems

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are not always keeping pace.

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So we have this kind of phenomenon where

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technology is advancing so rapidly.

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And in the health care space, a lot

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of our administration

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systems, payment systems,

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really are not keeping pace, and therefore, that

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just opens the door for fraudsters

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really to continue to advance

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and perpetrate fraud across the health care industry.

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And this is again, you have to you

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have to monitor too. You have to consistently

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keep up with this technology that's advancing

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so incredibly fast, and you have to have

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to be able to watch these technologies advance

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and then be able to

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react, which brings me to my next question,

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which is something that I think we all

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deal with when something happens often. You know,

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it's a reactive process. Okay. Something happens. Well,

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I guess I have to change this. And

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this is something that also happens a lot

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in threat and potential fraud. Organizations are dealing

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with something, and then they react to that.

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But

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should there be an aspect of this

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where

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it should be a proactive

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process,

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especially

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in the payment integrity space? And and do

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they need to be really, do they need

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to be proactive

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right now?

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And how can they do that?

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We definitely need to be proactive. I think

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you recognize that once the money is out

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the door, it's very

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difficult to claw that money back, as we

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call it, especially from from true fraudsters, more

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like organized crime. When it's a good provider,

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maybe gone bad, it might be a little

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bit easier. But the reality is most of

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the time, the money is out the door,

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and it's very costly,

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right, to to go through that legal process.

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So,

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you know, I think that

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being proactive,

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you know, is going to help us in

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in so many ways. But I think there

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are some things that we have to really

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consider. So first of all,

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payment processing is regulated,

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and therefore, there's processing times to be met.

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And so when

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a claim needs to be paid, it's governed,

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and payers need to meet those obligations.

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And so, historically,

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anything that slowed that payment processing down, like

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a fraud prevention measure,

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it was usually shelved or rejected entirely, and

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the companies would take the risk because,

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again, they're trying to meet in the regulation

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time periods, but also, obviously, trying to pay

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the providers

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and clinicians in a timely manner.

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And so I'm not saying it's working against

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each other, but there's many things to consider.

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And historically, some of the fraud prevention

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kind of

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proactive measures, it's very was very manual.

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And so the the, you know, a payment

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has to be made. It takes 4 days

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to research. We're way past the time of

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payment processing.

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So, you know, it that's been a challenge.

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But, you know,

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the amount of loss to the health care

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industry

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and their clients and members

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has reached just a staggering amount, which you

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talked about early,

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in the tens of 1,000,000,000. And and I

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would I would beg to say it's probably

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getting close to 100 of 1,000,000,000, to be

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honest. Probably more. Yeah. Couple years. Right?

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It kind of just depends upon on where,

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you know, you get your dataset from. But

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the reality is is that it's putting a

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financial strain on the health care system

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and also the welfare of the health care

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industry.

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And so we really need to be proactive

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in trying to help reduce the the losses,

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which then, you know, all comes back within

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to the company and and the clients and

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the members. You know? And so

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we need to start to look at kind

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of fast and effective ways

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to really put suspicious actor detection upfront

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in the payment processing and operation procedures that

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we have in the health care industry.

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Yeah. And you've mentioned sort of the the

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rapidly evolving technology

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around these around around the space, really. And

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fraudsters certainly use that rapidly

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expanding

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sphere and and the technology to their advantage.

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But, again, being proactive, I think organizations

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can do the same thing, and and health

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care can do the same thing. What are

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you seeing as some of the strategies

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and and specifically sort of the innovations that

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you're seeing in the space

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that are showing promise

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to really reduce that staggering number that we

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just talked about?

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Yeah. I think I think things like APIs,

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which is, you know, the ability to rapidly

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stream data and information

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within the comp a company but also across

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company lines, a company to company b to

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b.

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I think the ability to really share information

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and and just share decisions,

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that technology is very helpful.

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Behavioral intelligence and data science is really at

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the core of of what we need to

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take advantage of now. And behavioral intelligence, if

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you don't really, you know you may have

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heard that more like in a CIA or

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FBI kind of thing, but

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it's really about watching the behavioral patterns

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of billing practices,

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potentially around providers,

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clinicians,

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and watching that with data science and looking

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at the patterns of behavior to really identify

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potential anomalies or suspicious activity. And so that

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that is something that I think is,

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really gaining stride right now,

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not just in the health care industry, but

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across industries. But the health care industries, you

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know, needs to start jumping into that space

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of where we're gonna be behind.

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The other thing is, you know,

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with that type of technology, whether it's APIs,

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behavioral intelligence and and data science,

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is really the ability to make those decisions

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at a much more rapid pace

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to work within those claims processing time frames.

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Yeah. I think that that's a key piece

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is the the the the response. How fast

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is the response? How fast can the response

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be? What's the speed like?

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That's huge. And any anytime you're dealing with

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with money, anytime you're dealing with some of

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these issues,

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specifically. And and one of the things that

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I think is is so hard in this

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space, specifically, is the fact that

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it's not going away. Right? It's fraud, waste,

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abuse. Those are always going to be things

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that health systems are going to be challenged

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with. It's going to evolve just like we

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talked about with the technology. There's going to

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be advances. There's going to be new things

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that are that are going to come up.

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What's the one thing, the one step leaders

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can take right now to be able to

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say, okay. I need to future proof. I

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need to prepare myself. What's that what's that

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one thing that you would like leaders to

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see do?

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Yeah. It gets back to that preventative measures,

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right, that we've talked about. But, you know,

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the health care is already complex,

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and I perceive it will continue to be

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with just technical advancements within the health care

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industry, how we care for our patients, medical

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advancements,

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and fraudsters, whether it's the individual organized crime

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rings,

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you know, or, you know, a good doctor

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potentially

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starting to go bad. Right? We'll continue to

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become more sophisticated in determining

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weaknesses that we have in the space of

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payment processing.

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And, again, they're going to be utilizing

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the same capabilities that we need to use,

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whether it's advanced technology or deepening their knowledge

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on how we do business

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to really continue to, you know,

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take fraudulent actions against us. But I think

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that the point of getting back to the

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question around one step, it's really gotta be

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around preventative measures through thought leadership and strategic

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prevention.

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So think in the manner of cybersecurity

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on how we protect our brand and clients

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and members and the amount of effort that

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goes into protecting the infrastructure

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of health care.

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We need to think of fraud

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in that same manner, and we need to

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think of it upfront when we're building new

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products,

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when we're bringing new clients in, when we're

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looking at our operation processes

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and maybe, you know, revisiting them or

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advancing them to new levels. We've gotta think

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of it upfront at that time.

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And, you know, the fraud prevention

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needs to have investment

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in the necessary

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tools

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and the support of those tools and those

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processes

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early on,

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not in the place where, you know, the

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company's already had major losses. You know, at

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that point in time, you're having to go

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back and and go back to the beginning

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and really think about the preventative measures that

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should have been done versus

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looking at at the time that you're implementing,

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you know, new clients and new operation processes.

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Yeah. Just like we talked about earlier, I

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think, again, that mindset of reactive versus proactive.

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Right? Something happens, yes, we can react to

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it, but that's not gonna help us in

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the long run. We might fix the issue

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there, but we're not gonna get any results

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right away. We need to think about being

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proactive instead of reactive. I think that's a

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that's a great point. Deb, I think we

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could go on and on about this topic.

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There's so many facets to discuss here, so

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many important issues to to bring to the

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light for a lot of different organizations. Is

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there anything else that we didn't touch on

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that you wanna mention that our listeners might

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benefit from?

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Yeah. I'd just like to say that Sirius

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is here to help. I'm here to help.

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You know, we do offer fraud system scanning,

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using some of the advanced technologies that we

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just talked about, behavioral intelligence,

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AI.

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We also can help, the SIU for lead

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support and lead identification through data analysis that

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we also talked about earlier.

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And then, obviously, in that, there's consulting services.

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Right? You know, with the experience that I

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have, that my team has, you know, we're

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here to help help you figure out where

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where to start.

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There's some businesses that are very advanced in

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this space, and there's others who just are

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trying to figure it out. We're here to

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help.

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Yeah. The space the space is so specific.

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Get get help. Have somebody take a have

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somebody take a look at what's actually going

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on. Right? That can that can make a

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huge difference. Don't do it yourself. Get a

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professional to be able to see, hey. What's

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actually happening here? I think that's that's a

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that's a great point as well. Deborah, thanks

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so much for your time and the great

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discussion today. Really appreciate it.

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You're welcome, Lucas. Thank you. Thanks, Deborah. And,

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again, I'd also like to thank Suresh as

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well for sponsoring this episode, and you can

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tune in to more podcasts from Becker's Health

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Care by visiting our podcast page at beckershospitalreview.com.