""There's a lot of fraud in the healthcare sector. The estimates on the conservative side are about $100 billion and, depending on who else you talk to, you can easily double or triple that with different calculations," said Jeneen Iwugo."
""My team uses AI to comb through those claims and that data and figure out where the risk is the greatest. I cannot investigate everything that looks weird, so I have to restratify my work to make sure that I am auditing and reviewing those instances where we have the biggest risk for something fraudulent happening.""
""The longer leash I get, the more I'm able to push the needle with using AI, getting into the agentic AI space, the more of that $100 billion I'll be able to recapture," she said."
""Once I get there, I will be able to take off and capture a lot more of the fraud that I know exists, that I'm able to detect, but that I'm just watching because I can't move fast enough.""
Artificial intelligence is enhancing the capability of the Centers for Medicare and Medicaid Services to identify healthcare fraud. The estimated fraud in the sector is around $100 billion, far exceeding the $1 billion budget for detection. AI tools assist approximately 500 employees in reviewing four to five million claims daily, allowing for focused audits on high-risk instances. The Trump administration's support has provided more flexibility in utilizing AI. Future programs aim to have AI recommend penalties for fraudulent claims, potentially increasing fraud recovery significantly.
Read at Nextgov.com
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