Data analytics are inescapable, whether you’re talking professional sports, political campaigns or the fight against health-care fraud. I recently shot a video on how this new world is affecting health care, a world where high-powered computer models are the new coin of the realm and where backroom data analysts are becoming superstars, helping to recover millions of dollars from fraudsters.
For example, the Health and Human Services Office of Inspector General maintains a team of 40 data analysts, tasked with combing through Medicare claims data and identifying suspicious billing patterns and outliers. And increasingly, field investigators are getting access to real-time data, instead of waiting weeks and sometimes months.
Some of the tools that are now in steady use include the Peer Comparison Generator, which lets field agents compare a provider’s billing behavior with his geographic peers. The tool can highlight suspicious billing practices and lead to full-scale investigations.
Successful data analytics are also behind the government’s temporary moratoria authority, which allows the Centers for Medicare & Medicaid Services to freeze Medicare enrollment for an entire category of providers in specific geographic areas. Moratoria can only be imposed if data analytics determine there’s a credible risk of fraud.
So far, moratoria are in place for home health agencies in Florida, Michigan, Illinois and Texas, as well as nonemergency ambulance providers in New Jersey, Pennsylvania and Texas.
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