The Latest Weapon to Fight Healthcare Fraud: Health IT and Analytics

January 10, 2014

Health IT and its data is rapidly becoming a powerful tool for the federal government in combating potential healthcare fraud nationwide.

Technology is playing a growing role in helping the government identify and combat potential healthcare fraud. It not only helps the government identify areas of fraud, but also makes it easier to share the results of its investigation with other agencies and health insurers.

Recently, the chief counsel of HHS' Office of Inspector General (OIG) testified before Congress regarding the growing role of information technologies and analytics - including data mining, trend evaluation, and modeling- to better identify fraud vulnerabilities and target their oversight efforts.  The OIG's data warehouse integrates data from Medicare parts A, B, and D so that the government can develop a comprehensive picture of beneficiaries' medical care and providers' billing patterns. The data warehouse also allows the government to work more quickly.

In fraud investigations, technology and databases have been increasingly used by Medicare Fraud Strike Forces, allowing quicker identification of fraud schemes and trends. The data-driven approach of the strike force is to pinpoint fraud hotspots through the identification of suspicious billing patterns and quickly target potential criminal behavior. Since their inception in 2007, strike force teams have charged more than 1,000 individuals with seeking to defraud Medicare of more than $2.4 billion.

Consequences to You

As a healthcare provider, this will impact how you, your peers, and the healthcare sector overall are targeted for investigation. As always, many healthcare investigations will continue to be opened based upon personal tips or whistleblower actions.

However, technology more easily allows the government to identify a provider as an outlier as far as billing a particular code. The government will also be able to use the integrated data to identify providers with certain billing patterns that appear suspicious. The fact that a provider services a certain segment of the population may make him a statistical anomaly that will have to be explained to the government. Mere dollar amounts may also put a provider on the government's radar. So a multi-office practice or a particularly busy office may be suspect based upon data alone.

One of the biggest changes is something we are already seeing. State agencies and insurance providers are increasingly becoming more active in investigating potential fraud. Because it is easier to share data, for example, an investigation that was not big enough for the federal government may be more likely handled at the state level. State medical boards are expected to become more active as well. And there likely will be more exclusions based upon state and private investigations for the same reasons.

Therefore, as a healthcare provider it is more important than ever:

• That your charting justify the codes you are billing, especially if you are billing for a more complex procedure;

• That you have a compliance program already in place;

• That you are able to show proactive measures to identify and return overpayments; and

• That you remember just because you do not accept Medicare or Medicaid, you are not automatically protected from a potential investigation.