How Artificial Intelligence is Detecting Healthcare Fraud

Throughout 2018, we saw how the federal government cracked down on healthcare fraud using a variety of technological advances

As we have written about over the years, data analytics is increasingly being used to identify inappropriate payments.

Through data mining and the use of predictive analysis, thousands or even millions of transactions, can be searched to detect patterns of questionable billing practices.

As we enter 2019, we can be certain that new avenues, including the use of artificial intelligence, or AI, will be explored to combat healthcare fraud. Late last year, Florida Atlantic University’s College of Engineering and Computer Science in Boca Raton released findings from a study they conducted using AI to detect Medicare fraud.

Researchers programmed computers to predict, classify and flag potential fraudulent events. They looked at Medicare Part B data from 2012 to 2015 focusing on detecting fraudulent provider claims within the data, which consisted of 37 million cases. They aggregated the 37 million cases down to a smaller data set of 3.7 million and identified a unique process to map fraud labels with known fraudulent providers.

“Our goal is to enable machine learners to cull through all of this data and flag anything suspicious. Then, we can alert investigators and auditors who will only have to focus on 50 cases instead of 500 cases or more,” said the study’s senior author Richard A. Bauder.

In Fiscal Year 2017, the government’s healthcare fraud prevention and enforcement efforts recovered $2.6 billion in taxpayer dollars from individuals and entities attempting to defraud the federal government and Medicare and Medicaid beneficiaries.

That same year, the U.S. Attorney General announced the formation of the Opioid Fraud and Abuse Detection Unit, a new Department of Justice pilot program that uses data to investigate and prosecute healthcare fraud related to prescription opioids, including pill mill schemes and pharmacies that unlawfully divert or dispense prescription opioids for illegitimate purposes.

Although still in its infancy, artificial intelligence, data analytics and predictive analysis, hold much promise in ferreting out those attempting to scam the healthcare system. By being proactive through the use of this technology, instead of reactive (i.e. pay and chase), federal agencies will be better able to recover and eventually prevent the loss of billions of dollars each year.

The Health Law Offices of Anthony C. Vitale has extensive experience representing clients in audits and overpayments and we can represent your interests through all of the stages of the overpayment appeals process. In addition, if you find yourself the target of a fraud investigation, our team can assist you every step of the way. Contact us for additional information at 305-358-4500 or send us an email to and let’s discuss how we might be able to assist you.

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The Health Law Offices of Anthony C. Vitale

The Health Law Offices of Anthony C. Vitale