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Demystifying A.I. for Healthcare Fraud Detection: Finding Value for the SIU
If you were lost, would you pull out a flip phone – with no flashlight, GPS or other apps – and expect it to help navigate you to your destination? Why then would you use the “flip phone” of fraud detection when a “smart phone” is available?
In partnership with a leading healthcare analytics academic institution for the last 15 years, one question has plagued ClarisHealth’s VP of Program Integrity Mark Isbitts: “Where does the true solution for the SIU lie?” While advanced technology can be a nebulous and confusing domain, it holds great promise for the SIU. Yet, the rules-based tools in use at many health plans – undeniably familiar and rooted in domain knowledge – still provide a great deal of value. As data processing power has risen exponentially, artificial intelligence has progressed from the theoretical to the practical for all areas of healthcare, including health plans. But, A.I. holds very little value without true domain expertise. Will it be as transformational for the SIU as the smart phone has been for modern life? Is the true solution to aid FWA efforts a platform that can combine domain expertise, traditional tools and true A.I.?
In this session, helmed by healthcare fraud and data science experts with decades of experience in the payer space, we break down common misperceptions around artificial intelligence for fraud detection so you can understand …
- Exactly what the industry means when the term “A.I.” is used
- What each application of A.I. offers to fraud detection and how they can help you overcome perennial healthcare data challenges
- How fraud detection models are built, why explainability has historically been a struggle, and how that impacts your trust in leads that are “pushed” to you
- Why domain expertise and true A.I. matter, plus why healthcare fraud looks much different than fraud in other industries (presented by a leading researcher and former SIU Data Scientist)
- How the SIU can find value with these modern fraud technologies, demonstrated with real-world technology that was developed by a team of data scientists at the University of Illinois-Chicago, headed by a leading FWA technology expert and professor on the subject
- How to compare FWA solutions based on technology-type, including what “true” A.I. does and how it functions
- A path forward that allows your FWA organization to integrate updated fraud detection solutions with your familiar rules-based tools and overall payment integrity efforts
- How this approach to your FWA program can be integrated across all of Payment Integrity
Kyle Cheek, PhD
Director, Center for Applied Analytics | Clinical Associate Professor, Information and Decision Sciences | College of Business Administration at The University of Illinois-Chicago (UIC)
Cheek has more than 20 years’ experience as an analytics practitioner and an executive in the health and life sciences industry. He has been at UIC since 2013. Prior to joining the UIC faculty, Cheek was vice president of payment integrity at United Health Care, vice president of analytics and informatics at Emdeon, and director of enterprise analytics at Health Care Service Corporation. Cheek holds a PhD in political economy and a Master of Public Administration from the University of Texas at Dallas. He holds a Master of Arts in political science and a Bachelor of Science in education from Midwestern State University
Vice President of Program Integrity | ClarisHealth
Isbitts has over 25 years’ experience working in the healthcare industry, including product management, strategic planning and consulting, marketing and business development. He is an expert in healthcare Payment Integrity as well as various Product Management and Product Strategy practices. He has a keen understanding of how to identify market needs and translate them into meaningful requirements, products and solutions in order to drive a company’s strategic direction to grow and build market-leading products and services. Isbitts holds a B.S. from the University of Michigan and a Master’s in Healthcare Administration from Mercer University.