Data Analytics and Data Sharing Help Fight Fraud in Healthcare Agencies

Federal health agencies are developing increasingly sophisticated methods to detect fraud and other forms of financial crime.

Federal agencies are using their investments in data analytics and artificial intelligence to better prevent fraud and other financial crimes.

Speaking at the Federal News Network Staying Ahead of Fraud, Waste and Abuse Seminar, representatives from Veterans Affairs, the Centers for Medicare & Medicaid Services (CMS), and HHS discussed how their agencies are reducing abuse of their services through to more sophisticated forms of detection.

The shift of financial aid and other services to digital platforms has left these agencies with many exploitable vulnerabilities. The number of transactions and recipients handled by these organizations is often immense, creating a corresponding demand to more effectively scrutinize their services for illicit or unnecessary use.

“Under Medicare, approximately 1.2 billion claims are submitted each year. Additionally, at the Centers for Medicare and Medicaid Services, in particular, we enroll 239,000 providers a year,” said Dara Corrigan, CMS director of the Center for Program Integrity, at the FNN Seminar.

One of the barriers to more effective fraud detection and prevention is human capital, specifically the amount of work required to manually review records and transactions for suspicious behavior.

“What we always try to do with our data analytics is to have the most correct and accurate data in the same place at the same time so that we can use algorithms and analytics to try to see where is the fraud going or where it might start… What we try to do when we prevent is to look for trends and share them with insurers so that we can detect fraud as soon as possible,” said Corrigan.

Using data analytics to better detect unusual behavior and identify malicious actors has led to collaboration between like-minded agencies, such as VA and CMS, adopting new anti-fraud techniques and sharing knowledge on best practices. VA has focused on adapting these practices over the past three years, in part to prevent fraudulent activity as it expands its community care programs.

“We have formed a task force with the Department of Justice, the Veterans Health Care Fraud Task Force, which we launched in October 2019,” said David Johnson, Deputy Inspector General of the Department of Justice. VA for surveys, during the FNN seminar. “It’s a strike force partnership that CMS and HHS OIG have already established and have a great track record. One of the things I wanted to emulate at VA is the robust data analysis programs that the [Medicare Fraud] Strike Force has a history of spotting potential fraud and trying to use it in our growing community care programs.”

The shift to managing services through online portals during the COVID-19 pandemic has increased opportunities for fraud, prompting agencies to further refine their detection approach and mitigate a recent surge in identity theft.

“COVID-19 and pandemic-related fraud schemes have taken center stage for the HHS OIG,” Miranda Bennett, HHS Assistant Inspector General for Investigations, said at the FNN Seminar. for false treatments and remedies. Then they moved on to fake vaccination card systems, and now they’re setting up fake COVID-19 testing centers that are really meant to get personal identifying information that can be used to submit fraudulent claims to programs.