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This insight piece by OptumServe is focused on AI and Program Integrity in Government, how commercial insight can factor in, and what can be learned from commercial technology to keep pace.

Applying Commercial AI, Program Integrity Practices in Government

Commercial organizations across the board have implemented artificial intelligence (AI) at scale and have successfully fine-tuned these technologies to identify, not just known fraud schemes, but emerging fraud and improper payment trends. By combining multiple methodologies, organizations can monitor Healthcare claims for emerging fraud schemes with unsupervised machine learning (ML) methods, while targeting known historical fraud behavior with supervised ML methods. Government agencies can apply these same practices to programs, such as Medicare, Medicaid, Veteran and military Healthcare, to automate decisions and administrative actions such as denial or rejection of claims, medical coding, chart reviews, and revoking providers or entities from billing eligibility. Ultimately, this reduces costs by automating manual processes, preserves federal budgets, and reduces unnecessary costs for beneficiaries.

Commercial Organizations Preparing Government for AI/ML

Industry leading technologies such as machine learning, a type of artificial intelligence, can be effective for Government agencies only if the necessary data sources are readily accessible for analytics and modeling. Many commercial organizations have decades of experience managing comparable Healthcare data including:

  • combining, storing, and maintaining dispersed data sets,
  • migrating big data from on-premise data centers to the cloud,
  • modernizing data storage and analytic technologies.

Proven best practices in the commercial space is continuing to modernize unified data warehouse through cloud-native technologies for commercial Healthcare data. Another benefit is enlisting an industry leader who has the experience in applying these practices and services to Government agencies for state Medicaid and federal Medicare programs. As data becomes centralized and more easily accessible, Government agencies can use technologies such as AI and ML for program integrity in preventing fraud, waste, and abuse, as well as ensuring quality of care across the spectrum. Establishing efficient and long-term practices surrounding data management ultimately improves quality and reduces costs in maintaining duplicative data warehouse systems.

Commercial Health Organization Technologies to Keep Pace with Advancements in Point of Care

Commercial health systems and health plan sponsors are recognizing traditional “where” care is delivered, i.e., in hospitals or doctor’s offices, are not always the best or most cost-effective sites of care. As a result, more care is now being delivered in the home, either by practitioners who visit the patient in their residence or via digital or virtual means. To facilitate this change, the commercial health sector has updated its billing, data management and privacy practices. For billing, they have had success with de-coupling the site of care from care delivered so that practitioners may be reimbursed for the services they render, regardless of where the care is delivered. Moving from on-premise, closed EMR scheduling and billing systems to cloud-based systems allows practitioners to access clinical histories and order additional services from anywhere; thereby implementing adaptable data management technologies and practices. Finally, site-of-care flexibility makes access to care easier for patients, but it also makes access to sensitive data easier for bad actors, further emphasizing the need for privacy and security practices continuing to advance to stay one step ahead, regardless of where that path leads.

About OptumServe

OptumServe is actively working with the broader Optum enterprise to identify the right technologies and solutions that can most effectively address the growing challenges in Healthcare, whether it be Healthcare costs, data management and exploitation, or outcomes. We hope to bring these technologies and solutions to our Government clients and partner with them to address these issues.




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