Tag: health care fraud

Artificial Intelligence | Fraud & Security Intelligence | Machine Learning
John Maynard 0
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

Analytics | Fraud & Security Intelligence
John Stultz 0
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

Analytics | Fraud & Security Intelligence
Ricky D. Sluder, CFE 0
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

Analytics
Jon Lemon 0
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,

Analytics | Fraud & Security Intelligence
Ricky D. Sluder, CFE 0
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

Analytics | Fraud & Security Intelligence
Greg Henderson 0
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

Data for Good
Ross Kaplan 0
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

Ross Kaplan 0
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

Analytics
Ross Kaplan 0
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

Data for Good
Ross Kaplan 0
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

Greg Henderson 0
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