How Identity Management Can Help Reduce Fraud in Healthcare

March 18, 2017

Identity theft and fraud is the fastest growing crime in the US. Specifically, medical fraud ranks as the fastest growing type of identity theft of any industry. According to the American Medical Association, 8 in 10 doctors have experienced some type of cyber attack. At the same time, clinics and hospitals also struggle to meet regulatory compliance. The Aberdeen Group reports, “only 61 percent of organizations had achieved compliance with regulatory frameworks such as SOC2, PCI DSS, 21 CFR Part 11, HIPAA, other regulations pertaining to personal health information (PHI) and GDPR.”

The impact of medical identity theft is more than $31 billion annually. While patient safety and data privacy take precedence, healthcare administrators are faced with economic pressures that can be reduced by achieving operational security and the efficiency of clinical workflows. In addition, medical identity theft and fraud can result in denied claims at a very high cost to healthcare providers. Another issue is how patient records are managed. According to the American Health Information Management Association (AHIMA) reports, 7%-10% of patients are misidentified when their enterprise master patient index (EMPI) and electronic health record (EHR) data is being searched at registration, and 6% of these patients experience an adverse event. According to the AHIMA, roughly 40% of duplicate health records have discrepancies caused by inconsistent records of patients’ first and last names.

Medical record overlays occur when patient information from one patient is used to replace another. Cleansing inaccurate patient records can be costly for healthcare providers. The average cost to resolve a single duplicate medical record is US$1,000. Master Data Management and Master Health Record Management initiatives minimize the number of ultimate duplicates but are delayed by days, weeks, and sometimes months. Vision to combat medical identity fraud and provide better patient administration, a real-time healthcare ecosystem is needed to support and manage:

  • Next-generation Healthcare
  • Consumer Engagement
  • Care Delivery
  • Payment Administration

To properly develop, you need to create an omnichannel patient engagement focus, but it also includes a widespread transformation in all aspects of care and administration. Healthcare organizations see increased competition for their share of consumer spending and mind share. Healthcare CIOs have already demonstrated their belief in this new direction by investing in EHR-based portals. These portals bring important capabilities for viewing claims, plan enrollment, as well as access to care and disease management information. With proper patient identification, health care providers decrease downstream risk to care and avoid costly duplicate records and overlays.

For more information, check out our Patient Identity Management white paper here.

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