The value of outside information


Most health care organizations either intentionally or due to some inability don’t use outside information (not just referals) in their search for fraud.  There are great numbers of valid reasons for this: HIPAA, security, usable/current data sources, inflexible information systems or processes, restrictive compliance & IT departments, and the list goes on and on.

That being said, in many cases it just comes down to a lack of perceived value from outside data, and consequently no pressure to incorporate it.  After all, most organizations have all the primary data for their customers and organizations within their four walls.  This may have been true (to some degree) in the past. However, with the current up-tick in fraudulent activity (in particular collusive fraud - such as organized crime), the use of external data becomes very important.

Many of the recent large fraud schemes committed against Medicare/Medicaid have involved using deceased provider NPI numbers, completely fictitious numbers, or deceased members – these are just some examples.  What many organizations now are considering is obtaining and utilizing other data sources to fill in the gaps.  One example is to subscribe to a service that provides updated business information, which could be used to determine if a DME (Durable Medical Equipment) supplier is providing the correct information (the true owner, actual address, etc.).  This makes it possible to validate if a DME is working with other DME’s or providers inappropriately.  Other organizations are doing things as simple as using one of the internet satellite views to view locations to validate facilities – is it a hospice, or an open field behind a garage?

Many regions have lists that are available of "bad" providers (in the US, both by state and federal), as well as invalid NPI numbers, and other inappropriate behaviors (deceased patients for eample).  The trick is incorporating the new information in a seamless fashion, so as to not make more work for what is usually an already over-burdened investigator.

The question becomes, can an organization in health care, with ever-increasing fraud activity gain from the use of outside information?


About Author

Ross Kaplan

Principal Solutions Architect

Ross Kaplan serves as the Principal Global Solutions Architect for Health Care in the SAS Security Intelligence global practice. He supports health care cost containment (Payment Integrity) initiatives across the Health & Life Sciences, State and Local Government, and Federal Government verticals. He has been active across North America, Europe, Middle East, Asia Pacific and South Africa. Providing industry expertise and vision at conferences and directly to customers, Ross has been at SAS for over eight years Ross is a 16 year veteran in the health insurance industry, focusing on analytics in health and condition management, member retention, and provider profiling prior to specializing in health care. He has assisted health plans, federal and State and local government agencies in defining their requirements and providing guidance in their solution advancement. Ross is also trained and experience in Healthcare privacy laws. Prior to SAS, Ross served as a solutions architect at Computer Associates and Siebel Systems, working with the Fortune 1000. He has supported other industries such as Insurance, Banking, and Pharmaceutical. However, his primary focus has always been in health care, receiving training in HIPAA and having direct input in Siebel’s health care product development. Ross has been featured speaker at many industry events focused on health care cost containment and payment integrity, most recently on the topic of social network analysis and link analysis, predictive analytics, and fraud/waste and abuse in the European market. Ross earned a bachelor's degree in Business Administration, with a concentration in Computer Information Systems (CIS) from San Francisco State University and his Master’s Degree in Statistics as well as an MBA with a concentration in Systems Analysis. Sales Training: • Consultative Selling • The Customer Delight Principal • Major Account Sales Strategy

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