What happens when a health care fraud scheme changes its spots?


In most of the articles and press pieces that speak of health care fraud, the topic is usually covered in broad terms regarding the type or activity that has taken place: over-billing to Medicare/Medicaid, services billed and not delivered, over subscription of medication (by members or Pharmacies), and the list goes on and on.

What is not evident at first glance is that the details and patterns associated with the various types of fraudulent behavior differ from region to region and continue to change over time. For example, it is generally accepted that fraud schemes begin in more populated regions and migrate to more rural areas over time. What is usually not mentioned, however,  is how the schemes themselves alter to adjust to new regions that they are moving into (accounting for different policies or regulations, for example). And more importantly, the schemes get smarter, having learned from their previous geography, what they can and cannot get away with.

As a result, it becomes exceedingly important and respectively more difficult for different health care companies (states, countries, insurance plans, etc.) to adjust to the new changes that a scheme has gone through.

Catching and even recognizing fraud is not as simple as saying, "a provider defrauded Medicaid by submitting false prescriptions." How does that provide a pattern to look for? And even if it did, now that it is a known pattern, one can be fairly certain that it will change to avoid easy detection.

Existing technologies can look for specific patterns, but what happens when the pattern changes? This raises the question that we should be thinking about in the industry: How can we more quickly adapt to identify a known scheme that has changed its spots?


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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