As part of an effort to identify and prevent health care fraud, RTI International was awarded a six-month project, worth almost a half-million dollars by the Office of the National Coordinator for Health Information Technology. Under terms of the contract, RTI researchers will work with the American Health Information Management Association (AHIMA) and SPSS to take a proactive approach to preventing health care fraud.
The company will develop functions and requirements for healthcare anti-fraud data collection in electronic health records (EHR), and the submission, compilation. It's hoped that analysis of such data that can be used to reduce the growing number of fraudulent claims and other improper payments against public and private health care plans.
"Currently, most fraud is detected post payment, which makes dealing with the claims very inefficient," said Colleen McCue, Ph.D., a senior research scientist at RTI and project manager. "If we can detect errors at the time the record is created, we can not only eliminate improper payments, but also improve the quality of care."
The research team will work with the National Health Care Antifraud Association (NHCAA), health care providers, health insurers, federal agencies, the Health Information Technology Standards Panel (HITSP) and the Certification Commission for Health Information Technology (CCHIT) to develop model anti-fraud requirements for electronic health records that will prevent, detect and support the prosecution of health care fraud as well as minimize opportunities for fraud.
"In some areas of the country, criminals have actually switched from drug trafficking to committing fraud against health care plans, because they consider it safer and more profitable," McCue said. "The model requirements that we propose will help officials predict when and how fraud may occur so they can manage resources and reduce its incidence."
Current estimates suggest that 3 to 10 percent of the annual U.S. health care expenditures are fraudulent. In 2001, the HHS Office of Inspector General found that $12.1 billion in Medicare fee-for-service claims should not have been paid.