Proof of concept finds $239 million in suspected healthcare fraud, waste, and abuse
Mastercard announced it recently completed a successful proof of concept coupling Mastercard’s artificial intelligence modeling technology with the Milliman Payment Integrity solution (MPI) to enhance detection of suspected healthcare fraud, waste, and abuse (FWA). Recognizing the value of this combined solution for their clients, Mastercard and Milliman have entered into a formal reseller agreement.
“The Milliman Payment Integrity team is excited about the enhanced fraud, waste, and abuse detection capabilities we can now offer our clients through the Mastercard FWA AI model”
The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to healthcare fraud are in the tens of billions of dollars each year – with some government and law enforcement agencies placing the loss as high as 10% of U.S. annual health outlays, or more than $300 billion a year.
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Milliman Payment Integrity is a multifactor, rules-based solution that audits health insurance claims to identify potentially inappropriate billing or providers engaging in FWA. Working with Milliman, Mastercard’s team of data scientists used its six-step AI model development process, AI Express, to develop three AI models that would leverage outputs from the Milliman Payment Integrity solution: a model to score provider-level risks, a model to evaluate claim-level risks and a combined model to evaluate the intersection of claims and providers.
The results were significant. Upwards of 80% of the claims identified by MPI from providers flagged by the AI model raised FWA concerns. When applied to a single mid-sized health insurance payer, the proof of concept identified more than $239 million in potential savings from 2,700 providers flagged for potential fraudulent claims.
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“Mastercard’s solutions designed to make payment systems operate more efficiently also provide the same benefits to the healthcare industry,” said Raja Rajamannar, Chief Marketing and Communications Officer and President of Healthcare at Mastercard. “Milliman’s objectives were to enhance its existing rules-based payment integrity solution with non-discreet testing capabilities. Leveraging our proprietary technology to build a custom AI model helped them to do just that – provide enhanced fraud detection and operational efficiencies to improve their customers’ experience.”
“The Milliman Payment Integrity team is excited about the enhanced fraud, waste, and abuse detection capabilities we can now offer our clients through the Mastercard FWA AI model,” said David Cusick, a Milliman principal. “Our proof-of-concept with Mastercard shows there is a very compelling value proposition when coupling our existing technology solution with Mastercard’s advanced AI and machine learning capabilities.”
Milliman clients who license MPI can now access the Mastercard AI Model for these enhanced FWA detection capabilities.
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