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Insurers tell Congress technology helps but human review and prepayment checks are needed
Summary
Independence Blue Cross and others urged stronger prepayment reviews, better data sharing and human oversight of AI tools; they warned criminals often outpace defenders and recommended coordination across payers and law enforcement.
Chris Deary, director of financial investigations at Independence Blue Cross, told the committee that analytics, machine learning and daily dashboards are valuable for spotting anomalous billing patterns but are only part of the solution.
"Technology is a multiplier in this space, and, there are amazing tools out there that allow us to look at these larger datasets in meaningful ways," Deary said. He and other witnesses recommended enhanced prepayment review, real‑time utilization monitoring, and better coordination among CMS, state agencies, private payers and law enforcement so actionable intelligence can be shared responsibly and promptly.
Deary described efforts to validate billed services with field work and beneficiary contact and said insurers often find coordinated networks that obscure ownership and exploit NPIs. He also noted that preventing the two necessary inputs for fraud — a valid NPI and beneficiary information — would be a high‑leverage target for policy changes.
Witnesses cautioned, however, that technology should not be the sole decision maker: human review is necessary to confirm clinical appropriateness before taking enforcement action, and insurers asked Congress for clearer legal pathways to share and act on data with CMS and partners.
