Smarter eligibility verification is within reach

Published: January 8, 2013 by Guest Contributor

By: Maria Moynihan

Fact:  In fiscal year 2011, the federal government allocated ~$608M to investigate and prosecute cases of alleged fraud in health care programs

Fact:  Medicare and Medicaid related scams cost taxpayers more than $60B a year

These statistics are profound, especially when so many truly need–and rightfully deserve–access to health benefits.  To make the facts a bit more tangible, how would you feel if you heard that neighbors of yours were submitting claims to Medicare for treatments that were never provided? In essence, you’ve got thieves for neighbors, don’t you?

Thankfully, government agencies are responding. Even while being challenged with reduced budgets and limited resources; they are investing in efficient processes, advanced data, analytics and decisioning tools to improve their visibility into individuals at the point of application.

By simply making adjustments to one or all of these areas, agencies can pinpoint whether or not individuals are who they say they are. Only with precision, relevancy, and efficiency of information, can fraud and abuse be curtailed.

Below are a few examples of how to improve your eligibility systems or processes today. Or, simply download the Issue Brief, Beyond Traditional Eligibility Verification, for more detail.

  • Use scores, models, and screening questions to assess a beneficiary’s true identity or level of identity fraud risk.
  • Use income and asset estimation models to compare to stated income as a validation step in determination of benefits eligibility.
  • Create a single system for automatic identification and verification of beneficiaries and businesses applying for service.
  • Tighten controls around business identity to weed out fraud rings, syndicates and other forms of business fraud.

The Bottom Line: Only with process, information, or system improvements, can government agencies move the needle on the growing and pressing issue of fraud and abuse.