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Future of Information
Healthcare
Dan Johnson
SVP Strategy Healthcare
October, 2014
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Experian Confidential.
Experian Healthcare
Fraud, Waste, and Abuse
Intent to
Deceive
 Between 3% - 10% of healthcare claims submitted are erroneous or fraudulent.
 Medicare estimated $50 billion in “improper payments” in 20101.
 Estimated 1-2% of overall healthcare “overpayment” is being caught or prevented.
 Healthcare spending in 2010 was 2.6 trillion, or 17.9% of GDP.
 Healthcare fraud alone is estimated to be 10% of expenditures, or $260 billion.
 Last year the federal government alone recovered $4.3 billion in healthcare fraud.
©2014 Experian Information Solutions, Inc. All rights reserved.
Experian Confidential.
Source: 1U.S. Office of Management and Budget, 2011
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Healthcare Fraud
Opportunities to Leverage Existing Capabilities
Identity Fraud
Eligibility Fraud
Types
 Bogus treatment
 Purchase
prescriptions
 Free treatment
 Credit card fraud
 Bogus providers
 Stolen identities
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Experian
Capabilities
ID Proofing &
Authentication
Device Intelligence
Commercial
Database
Protect My IDalerts
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Experian Confidential.
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Types
Unlicensed
provider /
pharmacist
Provider
Verification
Entity Verification
Patient Eligibility
Employee
background
Experian
Capabilities
 ID Proofing
 Commercial
Database
 Public records
Claims Fraud
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Types
Phantom
treatments
Double billing
Poor care –
follow-up req
Un-needed care
Bogus insurers
Free services
Inflated lab tests
Runners – tests
Experian
Capabilities
 PaymentSafe
 Identity Proofing &
Authentication
 Device Intelligence
Prescription
Fraud
Types
 Fake scripts
 Stolen scripts
 Free prescriptions
Experian
Capabilities
 ID Proofing &
Authentication
 Credentials
 Device Intelligence
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Experian Healthcare
Strategic Initiatives
 Healthcare Patient Matching
(PIN) project
 Experian Secure Storage
(ESS)
 Payment Factoring
 Medical Identity Alerts
 Full-file Reporting by
Hospitals
 Portal Protection (Precise ID
and FraudNet)
 Data Lab analytics
 Concept – Fraud Bureau
©2014 Experian Information Solutions, Inc. All rights reserved.
Experian Confidential.
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Experian Healthcare
Strategic Initiatives: Data Lab Analytics
Passport Data Sample
 520M HL7 records
 Patient demographic
information (non-PHI) only
 ~30M individuals
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Experian Confidential.
Analysis
 Number of unique patients
 Data trends and
correlations
 Assess matching algorithm
Goals
 Consumer medical identity
alerts
 Patient identity matching
 Support development of
UMPI
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