A Team Approach to Fighting Fraud

New Coalition to Share Information
A Team Approach to Fighting Fraud

By sharing information, a new coalition of 21 private insurers, government agencies and others can do a better job of tackling health insurance fraud, says WellPoint's Lee Arian.

See Also: OnDemand | Defining a Detection & Response Strategy

"We obviously understand there's a limited supply of dollars that can go toward medical care, and we all want it to go toward good care, necessary care, and not get into the hands of those who shouldn't be getting it," says Arian, WellPoint's staff vice president of program integrity, in an interview with HealthcareInfoSecurity's Marianne Kolbasuk McGee (transcript below).

Health insurer WellPoint joined the healthcare anti-fraud coalition, which was recently launched by the Obama administration, to work together more closely with others to curb healthcare fraud, Arian says. "I think there's a lot the government can learn from us and we can learn from the government," he explains.

A key goal is to use the vast amount of data each coalition member has to identify "aberrations and outliers" in healthcare billing.

"We need to focus our efforts, and if we can bring together the strength of the government along with some of the data capabilities of private insurers, I think we can do a much better job of curbing fraud and abuse," Arian says.

In the interview, Arian discusses:

  • Why WellPoint joined the coalition;
  • What the healthcare industry can expect from the coalition and how soon some tangible results might be seen;
  • How coalition members could share de-identified claims data to detect fraud;

As staff vice president of program integrity, Arian oversees WellPoint's fraud and abuse department that includes investigative teams, including provider auditing. Before joining WellPoint in 2004, Arian spent 13 years as an assistant U.S. attorney in Los Angeles, an experience that he says prepared him for his work with the coalition.

WellPoint's Audit Team

MARIANNE KOLBASUK MCGEE: Tell us a little bit about your organization and your role. And also in the context of the background you have as an assistant U.S. attorney in LA, what will that experience bring to your work with the coalition?

LEE ARIAN: Within WellPoint, I oversee our fraud and abuse team and our provider audit team across the WellPoint enterprise, which consists of 14 Blues plans across the country. We also do business for state-sponsored or Medicaid plans outside of our Blues plans. The enterprise is obviously large in scope, and we have teams really divvied up doing what we call special investigations, which really are investigations into fraud and abuse. We have a clinical team that's headed by a physician and has nurses on it who provide us with clinical insight into coding and billings. And then we have a data analytics team which is headed by someone who's experienced with actuary and actually has a master's in mathematics. We have what I would like to think is a fairly broad expanse of experience within our team to look at some of the issues related to fraud and abuse. As I mentioned, I also oversee a provider audit team, which does specific routine audits. It's less about, say, fraud, but plays into the abuse area.

With regard to my background, as you mentioned I was for 13 years as an assistant U.S. attorney in Los Angeles. I think what that brings to the coalition and to my job in general is some credibility with law enforcement agencies, with prosecutive agencies, and really an understanding of how to work with the government and an understanding of some of the issues that the government may have in working across with the private sector.

Detecting, Preventing Fraud

MCGEE: Why did WellPoint join the coalition, and what insights about detecting and preventing healthcare billing fraud will you bring to the group?

ARIAN: [With] my background, I obviously have an affinity toward working with the government. So we joined in part because of that and part because we see it as an important role for insurers overall to be connected to government efforts to curb fraud and abuse and that will hopefully help our efforts. Again, we're all in it together in terms of saving medical dollars from misuse. We obviously understand there's a limited supply of dollars that can go toward medical care, and we all want it to go toward good care and necessary care and not get into the hands of those who shouldn't be getting it. So it's important for us to join together on a broad scale.

I think there's a lot the government can learn from us and we can learn from the government. And primarily the learning involves data and what comes out of the data so that you can see aberrations [and] outliers across the spectrum, and that will help us identify the few providers that we want to focus on, and I say that in all seriousness. It's a big problem, but it's a problem limited in nature. The vast majority of the providers in this country are out there doing a good job and billing appropriately and want what's best. But there's a small percentage who are taking advantage of the system, and that's where we need to focus our efforts. If we can bring together the strength of the government along with some of the data capabilities of private insurers, I think we can do a much better job of curbing fraud and abuse.

Coalition Expectations

MCGEE: What can the healthcare industry reasonably expect the coalition to accomplish and, when do you think you'll see some tangible results?

ARIAN: Realistically what we can see accomplished is some level of working closer together, but there are hurdles. As a former prosecutor, I recognize that you may not want to share too much with others because you may be working on a criminal case and there are aspects of that case that you don't want to be out in the public until you're ready to indict someone. So that's a hurdle; that's an issue.

On the other hand, an area where I think we could work better together and stop some of the bleeding before too long is, for instance, government becomes aware of qui tam actions, which are basically whistleblower actions. If we can devise a way where private insurers can learn of those actions in cases where we know there's going to be no criminal aspect to the action, well maybe we can slow the payments to some of these providers who have issues that we know aren't going to be criminal in nature, but we can deal with through process and through ways to reduce the amount of payments we're making while the government is investigating the qui tam actions. That's just an example of something we could do and work together to do that would have a significant impact to the payments that are going out in the system inappropriately.

How quickly can we see something? I know the coalition is working toward some actions that have some impact, so hopefully we will see something in the next - I hate putting a number on it - several months; perhaps we'll see some results out of the coalition.

Sharing Best Practices

MCGEE: How will WellPoint share best practices with the group?

ARIAN: We're still working through some of those issues today. It looks like where we're headed is toward some level of de-identifying the information so that there are no privacy concerns and the like, but issue-driven matters will be shared so that it doesn't focus per se on a particular member or anything like that so that we can share it without some of the privacy concerns. We're also looking at ... working through a third party who will obtain some of the data and ensure that it's de-identified in such a way that it can be useful to what we're trying to accomplish, but at the same time ensure some of the privacy concerns are addressed. That's an issue that the coalition is working through. I think we're feeling pretty good about having some solutions in place for that.

What we bring to the table is a mass of data. We have 33 million members across the country, approximately, so we have a lot of data that can help us identify outliers and issues of concern. If we bring the issues to the coalition, I think we'll start seeing some impact if we have other insurers working to do that and then the government coming in and doing the same. It's really a matter of working together to identify the issues. And I think we can do that together better than separately.

Exchanging Information Securely

MCGEE: You mentioned de-identified data. Will coalition members be sharing claims data and, if so, for what purposes? And it sounds as though the patient information will be kept confidential by the de-identification.

ARIAN: I think we're probably going to see that it will be de-identified and confidential. Again, these are some of the issues frankly we're working through, so I'm not sure I have specific answers for you. But there will be process and protocol in place to ensure appropriate confidentiality while also ensuring that what's shared has some usefulness. For instance, if Doctor X's prescription patterns are significantly different from what one would expect or if Doctor X doesn't have many patients and his patients don't have many medical visits but [they] have significant prescriptions coming from him, we can share that issue and concern without delving into specific patient or member-based data. I think that type of sharing of information will be helpful.

MCGEE: Will members of the group be doing any co-development work or pilots together?

ARIAN: I think that's possible. I think we're early in the stages. I know we've had some discussions with another large player about working on a pilot together, but I don't want to jump the gun and say definitely so or definitely not. It's certainly in the discussion stages.

About the Author

Jeffrey Roman

Jeffrey Roman

News Writer, ISMG

Roman is the former News Writer for Information Security Media Group. Having worked for multiple publications at The College of New Jersey, including the College's newspaper "The Signal" and alumni magazine, Roman has experience in journalism, copy editing and communications.

Around the Network

Our website uses cookies. Cookies enable us to provide the best experience possible and help us understand how visitors use our website. By browsing healthcareinfosecurity.com, you agree to our use of cookies.