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Data analytics and healthcare fraud in 2020

2020 is a year that has pushed us to embrace technology. The current coronavirus pandemic has led many to transition from working in an office or other location to working from the home.

How have these changes impacted healthcare providers?

In an effort to reduce the risk of exposure to this virus, medical professionals have revamped some of their services to provide telehealth options where available. The United States Centers for Medicare and Medicaid Services (CMS) has embraced these changes by increasing the number and types of covered telehealth services.

These changes are likely just the beginning. In addition to providing services online, the watchdogs who monitor healthcare professionals are also shifting their enforcement efforts. Government agencies are increasingly relying on software and cloud-based solutions to help detect healthcare fraud.

How does the government use data analytics and cloud-based solutions to move forward with healthcare fraud charges?

Government agencies use data analytics to watch for any changes in Medicare claims. This type of software flagged a surge in claims for reimbursement for genetic tests for cancer, leading to an investigation and dozens of allegations of healthcare fraud. This tool allows investigators to gather evidence to support the claims – evidence that in the past was often only available if a former employee or co-worker came forward with a whistleblower claim.

In most cases, the software works by analyzing billing patterns. Any patterns that are unusual or suspicious when compared with previous billings are flagged for further review. Investigators will then review the flagged billings and look for instances of fraud. Examples could include billing for medically unnecessary procedures or upcoding claims. If enough evidence is gathered, the government may move forward with criminal charges.