Using big data to combat fraud


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The Centers for Medicare and Medicare Services outlined Nov. 13 at Health IT Day 2013 its use of big data to transform health care.

CMS is leveraging big data to reduce Medicare and Medicaid claim fraud by collecting analytics and increasing open data, according to Shantanu Agrawal, director of the data sharing and partnership group at CMS.

A provider-screening process is able to capture critical attributes that may help identify fraudulent health care providers. CMS is then able to use software to sift through the 4.5 million claims CMS receives a day and run them through algorithms that search for patterns of fraud.

“There is no way that CMS can do this without technology…we can bump those claims against algorithms,” Agrawal said, speaking at the event organized by AFCEA Bethesda in Bethesda, Md.

“We have numerous algorithms at this point that range from basic outlier algorithms to data predictive models.”

CMS’ goal is to find a balance by having users do as little as possible to sign up on the website, while still avoiding fraud. However, money that goes to providers fraudulently needs to be recouped by private contractors, which the government pays.

CMS has also created the Open Payments Program as part of the Physician Payment Sunshine Act. The program is aimed at exposing the financial relationships between teaching hospitals and the medical industry.

These financial exchanges “happen all the time; they’ve happened for years and years and years and generally speaking, you and I are totally unaware of it,” Agrawal said.

The goal of the program is to make those relationships transparent by collecting the financial data, as well as data on the physicians and hospitals and make it available on a public website.

“I think then the real question is opened up, which is, ‘what do these interactions mean for utilization and policy?’” Agrawal said.

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big data, data analytics, Tech
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