Personally, I love studies. They help put things into context, and when done well, provide an independent and hopefully unbiased view of the forces that shape our lives. They are also a great way to see government funds used in strange ways. For example, the new NIOSH (National Institute for
The first step is to answer the question of what “real-time” actually means. Depending on the program and industry speed of response, I’ve heard answers that varied from milliseconds for the biggest banks in processing credit card charges to 24 hours for some government programs. A better description of what
Fraud detection presents myriad analytical challenges: gathering sufficient known cases to make typical modeling techniques possible, gathering inputs from disparate data sources, and combining expert knowledge from investigators with findings to be gleaned from the data in an efficient way. Of course, analysts can fall into the trap of thinking
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
In the health care field, the impact of fraud, waste and abuse on payers -- whether insurance companies, government agencies or self-insured employers -- is enormous. Fraud losses weaken a payer’s financial position, with fraud loss estimates rivaling net income. Fraud losses feed the escalating care cost curve, undermining a
