Governance & Risk Management , Incident & Breach Response , Managed Detection & Response (MDR)

Fighting Healthcare Payments Fraud

IBM's Robert McGinley on How to Counter the Latest Scams
Fighting Healthcare Payments Fraud
Robert McGinley, IBM

When it comes to healthcare payments, fraud tends to come in two flavors: Organized and opportunistic. What are the biggest gaps in detecting and preventing these schemes? IBM's Robert McGinley shares insight.

Awareness is a challenge with healthcare payments fraud, and so is analytics. But a huge part of the problem is the healthcare regulatory environment itself, says McGinley, who is Global Lead within IBM's Healthcare Counter Fraud and Financial Crimes Strategy & Analytics group.

"A major driver of all these gaps is that the healthcare ecosystem is really built on a regulatory foundation that requires these organizations to pay these claims very quickly, and then subsequently have to chase those bad claims."

In other words, the fraud has been committed before detection even begins.

In an interview about fighting back against the newest healthcare payments fraud schemes, McGinley discusses:

  • Today's biggest healthcare fraud prevention gaps;
  • The role of data analytics in detecting and investigating fraud;
  • Lessons that healthcare can learn from other sectors.

McGinley, Global Lead for IBM's Healthcare Counter Fraud Center of Competency, has over 28 years of experience in fraud risk management and operations. He has extensive skills in engagement leadership, risk and fraud analytics, claim and special investigation operations, advanced analytics, solution design, and research and development. McGinley works with private and government organizations throughout the United States, Canada, South America, Africa and Europe.

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