Analytics Turns Up the ‘Heat’ on Healthcare Fraud

It’s been a year of steady and encouraging progress in the fight against fraud and waste in the healthcare sector. The Inspector General’s office reports an expectation of significant total savings in many sectors for fiscal 2010, with a noteworthy $3.8 billion coming from investigative receivables.

 

“…We are particularly encouraged by the success of our partnerships with HHS and the Department of Justice through the Health Care Fraud Prevention and Enforcement Action Team (HEAT),” Inspector General Daniel Levinson said in a news release.

 

Use of advanced predictive analytics in preventing fraud & waste is gaining a prominent role in the battle. At a recent healthcare fraud prevention summit HHS Secretary Kathleen Sebelius and Attorney General Eric Holder announced that the CMS will be acquiring new analytic tools. The CMS is soliciting for “state of the art, fraud-fighting analytic tools to help the agency predict and prevent potentially wasteful, abusive, or fraudulent payments before they occur.” It’s the “before they occur” aspect of the analytics that brings the greatest potential for arresting and reducing the sharply rising costs in the current healthcare system.

The CMS, with new and expanded authority,
Will be able to take anti-fraud action before a claim is paid.

 

“By using new predictive modeling analytic tools we are better able to expand our efforts to save the millions – and possibly billions – of dollars wasted on waste, fraud and abuse.” said CMS Administrator Donald Berwick, M.D.

 

Customizable analytics software & services such as IBM’s Fraud and Abuse Management System is providing the state of the art solutions now needed. ‘FAMS’ is capable of sorting through information on tens of thousands of providers and tens of millions of claims in a matter of minutes…creating suspicion indices using almost 1,000 behavioral patterns in a wide range of specialties. The highly customizable system yields rapid results as the analytic modeling tools reveal potentially fraudulent activity, waste, mis-management of funds and other sources of loss. The software, tools and services needed to combat fraud and plug many other fiscal leaks in our ailing healthcare system are ready for frontline deployment.