Hi, everyone. This is Lucas Voss with Becker's
HealthCare and the Becker's HealthCare podcast series. Thanks
so much for tuning in today, and I'm
very excited to be joined by Deborah Hamer,
the director of product FWA Solutions at Cerus.
And we have a very exciting
topic to discuss, lots to discuss there. We'll
talk about fraud, waste, and abuse in the
payment integrity space. Deborah, thanks so much for
joining us.
You're welcome, Lucas. Nice to meet you. To
get us started here, can you introduce yourself
and just give us an overview
of your experience in healthcare?
I can. So as you mentioned, I'm Deb
Hamer, and I'm the product development director at
Cerus,
focused on fraud, waste, and abuse products and
services.
I have 30 years in the technology development
space with 15 of that within the health
care industry at 2 pretty large health care
companies.
And my focus and experience has been in
the area of software development and data science,
focused primarily
on the provider systems
and claim systems,
with, some focus also in big data,
artificial intelligence, machine learning,
and cybersecurity and fraud.
And that space has developed so much too.
So much experience
here. Again, Deb, thanks so much for for
joining us. Really appreciate it. When I looked
at some of the numbers associated
with with fraud, waste, and then also the
abuse that happens, it it was really staggering.
Tens
of 1,000,000,000 of dollars really annually. And there's
a lot of a lot of numbers that
we don't really know. It might be higher,
which is incredible.
Why should health care organizations
focus on getting the processes around this topic
right
right now and address the issue most importantly
today?
Yeah. I think there's there's 2 core reasons.
1,
technology continues to advance at such a rapid
pace. All of us are hearing about AI.
Right? And, actually, AI has been around for
a long time, but it's becoming mainstream.
And then the second is around administrative systems
are not always keeping pace.
So we have this kind of phenomenon where
technology is advancing so rapidly.
And in the health care space, a lot
of our administration
systems, payment systems,
really are not keeping pace, and therefore, that
just opens the door for fraudsters
really to continue to advance
and perpetrate fraud across the health care industry.
And this is again, you have to you
have to monitor too. You have to consistently
keep up with this technology that's advancing
so incredibly fast, and you have to have
to be able to watch these technologies advance
and then be able to
react, which brings me to my next question,
which is something that I think we all
deal with when something happens often. You know,
it's a reactive process. Okay. Something happens. Well,
I guess I have to change this. And
this is something that also happens a lot
in threat and potential fraud. Organizations are dealing
with something, and then they react to that.
But
should there be an aspect of this
where
it should be a proactive
process,
especially
in the payment integrity space? And and do
they need to be really, do they need
to be proactive
right now?
And how can they do that?
We definitely need to be proactive. I think
you recognize that once the money is out
the door, it's very
difficult to claw that money back, as we
call it, especially from from true fraudsters, more
like organized crime. When it's a good provider,
maybe gone bad, it might be a little
bit easier. But the reality is most of
the time, the money is out the door,
and it's very costly,
right, to to go through that legal process.
So,
you know, I think that
being proactive,
you know, is going to help us in
in so many ways. But I think there
are some things that we have to really
consider. So first of all,
payment processing is regulated,
and therefore, there's processing times to be met.
And so when
a claim needs to be paid, it's governed,
and payers need to meet those obligations.
And so, historically,
anything that slowed that payment processing down, like
a fraud prevention measure,
it was usually shelved or rejected entirely, and
the companies would take the risk because,
again, they're trying to meet in the regulation
time periods, but also, obviously, trying to pay
the providers
and clinicians in a timely manner.
And so I'm not saying it's working against
each other, but there's many things to consider.
And historically, some of the fraud prevention
kind of
proactive measures, it's very was very manual.
And so the the, you know, a payment
has to be made. It takes 4 days
to research. We're way past the time of
payment processing.
So, you know, it that's been a challenge.
But, you know,
the amount of loss to the health care
industry
and their clients and members
has reached just a staggering amount, which you
talked about early,
in the tens of 1,000,000,000. And and I
would I would beg to say it's probably
getting close to 100 of 1,000,000,000, to be
honest. Probably more. Yeah. Couple years. Right?
It kind of just depends upon on where,
you know, you get your dataset from. But
the reality is is that it's putting a
financial strain on the health care system
and also the welfare of the health care
industry.
And so we really need to be proactive
in trying to help reduce the the losses,
which then, you know, all comes back within
to the company and and the clients and
the members. You know? And so
we need to start to look at kind
of fast and effective ways
to really put suspicious actor detection upfront
in the payment processing and operation procedures that
we have in the health care industry.
Yeah. And you've mentioned sort of the the
rapidly evolving technology
around these around around the space, really. And
fraudsters certainly use that rapidly
expanding
sphere and and the technology to their advantage.
But, again, being proactive, I think organizations
can do the same thing, and and health
care can do the same thing. What are
you seeing as some of the strategies
and and specifically sort of the innovations that
you're seeing in the space
that are showing promise
to really reduce that staggering number that we
just talked about?
Yeah. I think I think things like APIs,
which is, you know, the ability to rapidly
stream data and information
within the comp a company but also across
company lines, a company to company b to
b.
I think the ability to really share information
and and just share decisions,
that technology is very helpful.
Behavioral intelligence and data science is really at
the core of of what we need to
take advantage of now. And behavioral intelligence, if
you don't really, you know you may have
heard that more like in a CIA or
FBI kind of thing, but
it's really about watching the behavioral patterns
of billing practices,
potentially around providers,
clinicians,
and watching that with data science and looking
at the patterns of behavior to really identify
potential anomalies or suspicious activity. And so that
that is something that I think is,
really gaining stride right now,
not just in the health care industry, but
across industries. But the health care industries, you
know, needs to start jumping into that space
of where we're gonna be behind.
The other thing is, you know,
with that type of technology, whether it's APIs,
behavioral intelligence and and data science,
is really the ability to make those decisions
at a much more rapid pace
to work within those claims processing time frames.
Yeah. I think that that's a key piece
is the the the the response. How fast
is the response? How fast can the response
be? What's the speed like?
That's huge. And any anytime you're dealing with
with money, anytime you're dealing with some of
these issues,
specifically. And and one of the things that
I think is is so hard in this
space, specifically, is the fact that
it's not going away. Right? It's fraud, waste,
abuse. Those are always going to be things
that health systems are going to be challenged
with. It's going to evolve just like we
talked about with the technology. There's going to
be advances. There's going to be new things
that are that are going to come up.
What's the one thing, the one step leaders
can take right now to be able to
say, okay. I need to future proof. I
need to prepare myself. What's that what's that
one thing that you would like leaders to
see do?
Yeah. It gets back to that preventative measures,
right, that we've talked about. But, you know,
the health care is already complex,
and I perceive it will continue to be
with just technical advancements within the health care
industry, how we care for our patients, medical
advancements,
and fraudsters, whether it's the individual organized crime
rings,
you know, or, you know, a good doctor
potentially
starting to go bad. Right? We'll continue to
become more sophisticated in determining
weaknesses that we have in the space of
payment processing.
And, again, they're going to be utilizing
the same capabilities that we need to use,
whether it's advanced technology or deepening their knowledge
on how we do business
to really continue to, you know,
take fraudulent actions against us. But I think
that the point of getting back to the
question around one step, it's really gotta be
around preventative measures through thought leadership and strategic
prevention.
So think in the manner of cybersecurity
on how we protect our brand and clients
and members and the amount of effort that
goes into protecting the infrastructure
of health care.
We need to think of fraud
in that same manner, and we need to
think of it upfront when we're building new
products,
when we're bringing new clients in, when we're
looking at our operation processes
and maybe, you know, revisiting them or
advancing them to new levels. We've gotta think
of it upfront at that time.
And, you know, the fraud prevention
needs to have investment
in the necessary
tools
and the support of those tools and those
processes
early on,
not in the place where, you know, the
company's already had major losses. You know, at
that point in time, you're having to go
back and and go back to the beginning
and really think about the preventative measures that
should have been done versus
looking at at the time that you're implementing,
you know, new clients and new operation processes.
Yeah. Just like we talked about earlier, I
think, again, that mindset of reactive versus proactive.
Right? Something happens, yes, we can react to
it, but that's not gonna help us in
the long run. We might fix the issue
there, but we're not gonna get any results
right away. We need to think about being
proactive instead of reactive. I think that's a
that's a great point. Deb, I think we
could go on and on about this topic.
There's so many facets to discuss here, so
many important issues to to bring to the
light for a lot of different organizations. Is
there anything else that we didn't touch on
that you wanna mention that our listeners might
benefit from?
Yeah. I'd just like to say that Sirius
is here to help. I'm here to help.
You know, we do offer fraud system scanning,
using some of the advanced technologies that we
just talked about, behavioral intelligence,
AI.
We also can help, the SIU for lead
support and lead identification through data analysis that
we also talked about earlier.
And then, obviously, in that, there's consulting services.
Right? You know, with the experience that I
have, that my team has, you know, we're
here to help help you figure out where
where to start.
There's some businesses that are very advanced in
this space, and there's others who just are
trying to figure it out. We're here to
help.
Yeah. The space the space is so specific.
Get get help. Have somebody take a have
somebody take a look at what's actually going
on. Right? That can that can make a
huge difference. Don't do it yourself. Get a
professional to be able to see, hey. What's
actually happening here? I think that's that's a
that's a great point as well. Deborah, thanks
so much for your time and the great
discussion today. Really appreciate it.
You're welcome, Lucas. Thank you. Thanks, Deborah. And,
again, I'd also like to thank Suresh as
well for sponsoring this episode, and you can
tune in to more podcasts from Becker's Health
Care by visiting our podcast page at beckershospitalreview.com.