Medicare Federal Investigators Getting Algorithms to Analyze And Find Fraud-Good Move as Contractors Efforts Are Weak With Risking Loss Of Transaction Revenue

This is a good deal if in fact it is available for use for the government and not outsourced to contractors as when you read the news, they are not making any waves when handling claims for Medicare in finding fraud as fraudulent claims as well as legitimate claims all add up to transaction fees, the most expensive and profit making area of healthcare today. The government is really on their own with the FBI and other agencies on catching fraud as to turn in Provider ABC that has ton of claim where many are algorithmically determined to be potential fraud cuts off the transaction money, conflict of interest you might say.

Medicare Contractor Gets Deal to Monitor Physician Incentive Payments–Same Folks Earlier This Week Admonished For Not Doing Enough for Fraud Prevention?

I mentioned too last year to look at who gets the anti fraud contracts, insurance interests or companies. They will of course keep their own exposure down but when charging the government for algorithmic transaction fees they want all of those they can get, thus not much gets done. When you have companies that are using extreme business intelligence algorithms for profit, kind of like what Ingenix does with their fraud prevention and they have another division that makes profits from transactions, well this is kind of like beating a dead horse and they are good at their formulas if you remember the underpayments that went on for 15 years and all the short pays. It only took 15 years to catch up with them with playing technology against those who did not have the IT resources to do a check and balance as was finally proven by Cuomo from New York. This kind of activity in healthcare data systems with claims has been going on for years. Again they will do fraud prevention very well on their own commercial claims, but when contracted to process for the government, keep those transactions coming in.

Medicare Fraud Prevention Has Cases Falling Through the Cracks–Looks Who’s Getting the Contracts And Check Out the Algorithms For Their Profitable Business Models

This could be interesting in another way too as they can keep a closer eye on the Medicare contractors as well. BD

Federal investigators will begin using sophisticated computerized analysis, much the way credit card companies and banks do, to fight increasingly clever and organized attempts to defraud the nation's health care system, officials said during a visit to Boston today.

Called predictive modeling, the modern tools will allow Medicare officials to spot providers who may be committing fraud in nearly real-time, and before the federal health insurance program for the elderly pays them for their services, said Health and Human Service Secretary Kathleen Sebelius in an interview. Sebelius and other federal health care officials are at UMass Boston today Thursday for a conference on preventing medical fraud.

The agency said it is soliciting proposals from companies to provide predictive modeling for the Medicare program, after testing the method in two pilot programs. Now, Sebelius said, the Centers for Medicare and Medicaid Services generally must track down potential violators after they've been paid, sometimes millions of dollars, and try to recover the
money.

Medicare sharpening tools to detect fraud - White Coat Notes - Boston.com