February 29, 2012
Health Care Fraud Trends and Data Mining Background
Fraud and abuse detection and deterrence is one of the most rapidly evolving areas of health care law. I found this backgrounder from Perkins Coie on recent developments very helpful. A few years back, Kathy Giannangelo wrote a good introduction to the use of data mining technology in the field. A few excerpts:
On the national level, the Centers for Medicare and Medicaid Services (CMS) created the Medicare-Medicaid Data Match Program, or Medi-Medi project, in 2001. . . . Federal regulations require that each state Medicaid agency maintain a claims processing and information retrieval system (the Medicaid Management Information System). The Surveillance and Utilization Review Subsystem, a mandatory component of the Medicaid Management Information System, exists to safeguard against inappropriate payments for Medicaid services. Patterns of fraudulent, abusive, unnecessary, or inappropriate utilization can be detected by analyzing and evaluating provider service utilization.
According to section 6034 of the Deficit Reduction Act, the Medi-Medi programs are to use computer algorithms to search for payment anomalies. The abnormalities being sought include billing or billing patterns identified with respect to service, time, or patient that appear to be suspect or otherwise implausible. This data-oriented approach to mining combined Medicare and Medicaid claims to detect improper billings and utilization patterns has created the ability to find vulnerabilities in both programs.
While the field of surveillance studies often critiques dataveillance, these strike me as model initiatives for the types of corporate audit trails that should be adopted far more widely in an economy as complex as ours.
February 29, 2012 | Permalink
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