5 types of fraud and how analytics can help
See how analytics fights back against ever-changing fraud trends.
Tag: health care fraud
Fighting fraud in the new world of Value-Based Payments
Ladies and gentlemen, I give you Value-Based Payments (VBP), health care’s new magic, “silver bullet” that will solve all our fraud problems. Last month, the US Department of Health and Human Services (HHS) issued a press release entitled, “HHS Proposes Stark Law and Anti-Kickback Statute Reforms to Support Value-Based and
Unasked fraud questions answered by AI
Artificial intelligence often seems misunderstood, especially in fraud. The same is true of machine learning. One of the amazing things about them is they ask the unasked questions. This occurs as artificial intelligence (AI) and machine learning (ML) go about their daily work. So, what is the unasked question? Too
Brother, can you spare a Healthcoin?
Blockchain technology and payment integrity in health care Blockchain technology has arrived in the health care space, bringing anticipation of revolutionary change in operational efficiency, data management, security, fraud prevention, disease prevention, and perhaps even in payments. While these are not new goals, I am ever the optimist. As almost
3 reasons why International Fraud Awareness Week matters to government
International Fraud Awareness Week is here! I know, I know… Fraud Week is not quite as exciting as Shark Week. It doesn’t appeal to your taste buds like Restaurant Week. Nor does it have the quirky feel of Brain Awareness Week (nope… I’m not making that one up!!). Nevertheless, Fraud Week is
What can agencies learn from massive Medicaid fraud busts?
On June 22nd, the U.S. Department of Justice announced the largest Medicaid fraud bust in history. The National Health Care Fraud Takedown included 301 defendants charged, $900 million in false billings, 61 medical professionals and 29 doctors, across 36 states. In another case, investigators in New York uncovered more than
Why Excel isn’t the solution for health care fraud, waste and abuse investigations
To prepare for the data challenges of 2015 and beyond, health care fraud, waste and abuse investigative units (government funded and commercial insurance plans, alike) need a data management infrastructure that provides access to data across programs, products and channels. This goes well beyond sorting and filtering small sets of
Fraud: An American health care epidemic
According to Time Magazine, the next Ebola outbreak will cost the World Bank in excess of $30 billion dollars. In 2014, America spent in excess of $1.16 million dollars to treat two victims of the dreaded disease. While Ebola and other microorganisms of the deadly variety are scary creatures there
Four-step approach to government fraud detection
Every day there are news stories of fraud perpetrated against federal government programs. Topping the list are Medicaid and Medicare schemes which costs taxpayers an estimated $100 billion a year. Fraud also is rampant in other important federal programs, including unemployment and disability benefits, health care, food stamps, tax collection,
Data Mining: A Medicaid Fraud Control Unit's best weapon in the fight against health care fraud
On a cold and wet December morning in 2008, at approximately 1:30 AM, I pulled into the parking lot of an abandoned supermarket in Arlington, TX. With sleet pelleting my windshield, I saw three additional sets of headlights enter into the parking lot from different directions. All three cars converged
It’s beginning to look a lot like International Fraud Awareness Week
For most people, this time of year means celebrating cherished, personal traditions… helping those less fortunate…flocking to stores in droves…the company holiday party… For the SAS Security Intelligence team, it means identity theft…benefits fraud…unemployment insurance fraud...insider threats. Why? Because next week is International Fraud Awareness Week! And we’re celebrating by
How long has health care fraud been hiding under the bed?
It has become more and more apparent, country by country and state by state, that many organizations do not have a clear grasp on what their exposure is to health care fraud. Whatever name it goes by – aberrant behavior, abuse, waste or fraud – and no matter how it is measured – in currency (dollars,
Is fraud a dirty word in health care?
It is becoming clear that a fair percentage of the health care community, particularity outside of the United States, are uncomfortable using the word, “fraud.” Instead, you see the words "risk" and "error" used more often to describe fraud. There appear to be many different reasons for the discomfort with
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
Is it fraud or abuse?
When discussing fraud and abuse, it often (very often) becomes a philosophical discussion of whether aberrant activities are fraudulent or abusive. The quick difference being that fraudulent is intentional and abuse is not. The distinction quickly becomes an issue of legal and illegal as opposed to right and wrong. What
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
The holy grail of pre-pay health care fraud
Everyone within the health care community recognizes that the traditional ‘pay-and-chase’ model for fraud cost reduction has some serious limitations. Recovery of the lost funds is in some cases a mere single digit percentage point (with some exceptions – but not many) of the moneys paid. And the effort and
Why life cycle management matters for health care fraud analysis
Due to the rapid changes in both the health care market and more specifically the amount of fraud being committed in it, it is even more important than ever to maintain some degree of life cycle management to update the analyses used to detect and identify aberrant activity. However, many
Health care fraud is on the rise
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
Feds stepping up to combat healthcare fraud
The federal government is more aggressively pursuing health care fraud, and helping the states do the same, by proposing funding changes and investing in new technologies. A newly proposed rule would allow 90 percent Federal Financial Participation (FFP) for data mining initiatives in state Medicaid Fraud Control Units (MFCU’s). Another