It took a while but in the last year HHS now enjoys some of the same algorithmic fraud detection methods as used by commercial insurers.  Of course it pays off as the alternative without this type of mining claims is that a lot more fraud gets through when hidden.  This is better than what we heard back in September of 2012 when all we accused of cheating with nothing brought to the table but I assume this was generated only by the point that recent news at that time showed higher expenditures in Medicare.  The government responses are getting uncannily similar to watching the bots on the stock market bot jumping around, as they react to what's in the news too except these are people and not bots:)  With numbers and algorithms they are up and down when you look at real time.

HHS and DOJ Send Letters to Hospital Trade Associations Warning of Gaming Billing System Via Use of Electronic Medical Records–Hospitals Just Learned How to Bill Better & Hired Consultants–Case of Being Algo Duped With Numbers?


Last week we had this, hurry up and write that code:)  Believe me every vendor that could do it faster would so what was up with this..more folks that don’t understand the short order code kitchen burned down a few years ago and these things take time. I said back in 2009 that it would take a 2-3 years before the job of HHS secretary would be about 80% Health IT related and here we have it today. 

Lack of IT or computer science here of late seems to be chasing a lot of folks out of jobs as it’s not easy to be a chief these days without some of this and be a non participant.  Today Small Business Exec announced leaving, so again it’s hard up at the top when you can’t walk and chew a little code now and then:)
  If you don’t have a little of this in your background then you think different too and data mechanic perceptions as to what is possible and time elements get way off.  I have had years of that and still see it today all over the social networks with perceptions from folks outside the industry way off from digital reality.  It’s not their job to know all oft this either but people in the industry should try to offer the layman a “real” explanation so one can learn a little and not have to rely on powdered up OMG media stories.  The PBS Frontline documentary looked bad too with the prosecutor, at least on the screen didn’t show any real body language of confidence, saw it in the first 5 minutes of talk.

Speed Up Rate of Change in Health IT?–“Short Order Code Kitchen Burned Down a Few Years Ago and There Was No Fire Sale”..IT Infrastructure Chance and Revisions Takes a Lot of ”Code”, “Time” and “ Most Importantly Money”

Back in July of 2012 there was this about the Office of the Inspector General learning their way around the software and it’s not much different in query that what some of the clearinghouse functions are, but you do see immediate patterns and can grab more low hanging fruit.  It works. 

HHS Office of Inspector General Learning Their Way Around Business Intelligence Algorithms to Detect and Find Fraud With An Analytics Approach

Tough at times to get Medicare contractors to kick in more as sometimes with all the subsidiaries insurers own today some may interact with others so by lowering money in one area it could shorten the intake in another subsidiary.  Some of the recovered money could have come right off methods like getting paid sooner by insurers too. 


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

Insurers Made $450 Million with Interest Income by Holding Medicare Funds for Around 46 Days Before Releasing Payment

One the process is in place a little longer the amount will level off with dollars saved as again the low hanging fruit with patterns will be found, although there’s always someone cooking up something new but history tells you that it will level at some point and then as you tighten down the parameters of the queries care is needed so as not to create mountains of false positives.  In addition there’s the most wanted list too and that’s good plus to have visuals out there an very visible. 

HHS Creates 'Most Wanted' List Website for Healthcare Fraud - Office of the Inspector General

For every dollar spent investigating healthcare fraud over the past three years, the government recovered $7.90, according to a report released on Monday by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius.

This was the highest three-year average return on investment in the 16-year history of the federal Health Care Fraud and Abuse Program, the report said.

The Obama administration has stepped up investigations under the program, making the prevention of fraud and waste in healthcare a top priority. The Patient Protection and Affordable Care Act authorized additional tools to fight fraud, including tougher eligibility screening for Medicare providers, increased data sharing among government agencies and greater oversight of private insurance abuses.


Post a Comment

Google Analytics Alternative