Nobody likes fraud and all those folks and their actions need to be caught for sure but in the midst of all of this a lot of questions arise too when analytics come into imageplay.  Hospitals and doctors use services that promise them maximum reimbursements too so sometimes you get down to some fine lines when reviewing claims and other information outside of the over all realm of out and out fraud. 

Insurers also use 3rd party companies here too so we have the battle of analytics and sales go through the sky to check and balance all over the place.  You can just read down further in the text here as they state “they have the best” just like all the analytics companies seem to say today.  Here’s a case that has been recently in the news with Prime Healthcare and other hospitals.  Did anyone do this on purpose, no, it was the algorithms that connected this, not bad doctors for goodness sakes, sold by 3M in this case that did the dirty work, so see where this is going?  One set of analytics competing with another set on the other side.  They all survive due to the complexity of today’s billing in the US with healthcare. 

Prime Healthcare Responds to Billing Practices–Flawed Data and Algorithms Once Again-Who Got Sold a Bill of Goods as Kaiser, Stanford & Other Hospitals Had a Ton of Kwashiorkor Malnutrition Billingsimage

Back in July of 2010 HMS Holdings bought Allied Management, another similar company in the medical claim business.

HMS Holdings Corp agrees to buy Allied Management for $26.2M – Algorithm and Transaction Income for Medical Billing Fraud and Auditing

Nobody really monitors the algorithms used and thus so it is becoming a battle of the math, again outside of the areas that are straight out fraud.  A couple years ago I suggested some of the math used could be looked to certify what algorithms insurers are using today either their own or those from 3rd parties.  We certify medical records but the payers have a free hand to apply what ever math they come up with relative to their costing algorithms. 

Rules on EHR Certification Should Take Back Seat to Certifying Insurance Algorithms At Present – We Need This First

So did the hospital or physician commit fraud or was it the 3rd party they used to secure “maximum” reimbursement…this is a good question today I think. 

Bad Algorithms in Healthcare Payment Systems and Risk Assessments–Did the Hospital Bill Fraudulently or Were They Sold Formulas That Did Not Conform

We have a ton of marketing going on today and granted auditing software is needed but many skew the numbers to present abilities that are flatly over rated in many area and marketers get paid big money to make a case for all the software too, meanwhile you and I just can’t get the care we need without everyone getting and analyzing their data first. Have you been suckered in?  Sometimes it’s hard to tell but listen in to the professor below who explains how numbers lie and how the marketing spins we have today make it hard. 

“Numbers Don’t Lie, But People Do”–Radio Interview from Charles Siefe–Journalists Take Note, He Addresses How Marketing And Bogus Statistics Are Sources of Problems That Mislead the Public & Government

Government gets fooled all the way around it seems and the sooner we come to the reality of what’s going on here, the sooner we might recover. Again there’s a need to find the people who commit fraud and get them out of the loop but when the analytics go on steroids to have hospital accounting systems battle it out with 3rd party auditing, we have not much more than “one more battle of the algorithms” and we all pay for that in our care for sure. This is part of what is driving up what we pay for care in the US. BD


Holdings Corp. HMSY +17.91% ("HMS" or the "Company") today announced a definitive agreement to acquire privately held HealthDataInsights, Inc. ("HDI") for approximately $400 million. The transaction is not contingent upon financing and is expected to close by December 31, 2011, subject to regulatory approvals.

HDI, a technology-enabled healthcare services company whose mission is to ensure claims integrity, identifies and recoups improper payments for health plans and government payers. Applying rules approved by the Centers for Medicare & Medicaid Services (CMS) and commercial health plan clients to identify fraud, waste and abuse, HDI reviewed more than $300 billion in paid claims last year. HDI is the exclusive Medicare Recovery Audit Contractor (RAC) in 17 states and three U.S. territories (CMS Region D), covering approximately 22% of all Medicare claims in the nation. According to CMS's FY 2010 Report to Congress on the "Implementation of Recovery Auditing at the Centers for Medicare & Medicaid Services," HDI's efforts in Region D accounted for 47% of the total dollars corrected by all four Medicare RACs.

Lucia added, "We expect that HDI's assets will accelerate our multi-year strategy of investing in new but related products and markets, and program integrity in particular. As the Medicare RAC with the highest recoveries and highest accuracy scores, HDI has best-in-class processes and technology, purpose-built for recovery auditing. Like HMS, HDI's services are primarily offered on a contingency-fee basis. In addition to expanding our Medicare business, the acquisition of HDI will provide us with expertise we can leverage in our state Medicaid RAC business."


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