Aetna pinches off fraud with data-mining, info-sharing tech

Part Three of a special four-part series
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healthcare fraud

Fraud prevention at Aetna, which focuses on proactive tactics to constantly stay on top of trends and root out potential fraudsters, has yielded very strong results for the insurer. It boasts a 15:1 return on investment--a number that incorporates the entire anti-fraud budget compared to what it recovers and saves.

"Sitting around and waiting for the proverbial phone call [of suspected fraudulent activity] isn't the way to do business anymore," Ralph Carpenter, head of Aetna's special investigative unit (SIU), told FierceHealthPayer. "We have set up a proactive model so that we look for fraud ourselves. We do a tremendous amount of data mining, engage in information sharing and keep our staff well educated as to what's going on out there."

One of the central elements of Aetna's proactive method is to leverage technology, which Carpenter said is "absolutely critical to deterring fraud." With the full support of Aetna's leadership, the insurer has invested in IT, such as its data-mining program that "basically searches out those providers or members who might be engaging in fraudulent activity and helps us get away from that old pay-and-chase model."

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"About 95 percent of our savings and recoveries were realized through dollars that were denied or reduced as a result of SIU investigations."

--Ralph Carpenter, head of Aetna's special investigative department
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The more than 100 employees within Aetna's SIU team use the technology to detect possible fraudulent activity. They then place smart flags on those providers, preventing their claims from getting through the system, which "drives down the recovery dollars before they go out the door," Carpenter said. "Last year, about 95 percent of our savings and recoveries were realized through dollars that were denied or reduced as a result of SIU investigations." 

If the SIU team suspects a provider of fraudulent activity, it reaches out to Aetna members about billing discrepancies and confirm whether certain services actually occurred. "We have direct reach out with our members, which most members really appreciate because they see it as a check and balance that they're not being charged for something they didn't actually receive," Carpenter said.

Aetna SIU team members also spend a lot of time and resources on training to stay up to date on what's going on in the fraud world, Carpenter said. The SIU team attends frequent meetings held by the National Health Care Anti-fraud Association, various task forces, law enforcement agencies and the Department of Health & Human Services. It also stays in "close contact," which can include weekly communications, with the FBI, attorneys general, state insurance departments and local law enforcement offices, he added.

Driving Aetna's active role in the fraud-fighting community is Carpenter's knowledge that communication leads to prevention. "We've learned that if we keep open lines of communication, internally and externally, we really can learn a tremendous amount of what's going on out there in the field."

"We have a recipe for success," Carpenter said, adding that Aetna is fortunate to have such a good fraud-prevention process in place. "But in the blink of an eye, something bad can happen." And so the company always remains vigilant, looking for the next fraud trend lurking around the corner. 

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