How can investigators predict healthcare fraud?

Predictive modeling is a term that has been used a great deal lately in the context of healthcare fraud.

In a nutshell, predictive modeling is the area of data mining concerned with forecasting probabilities and trends. Here in South Florida, many of us are familiar with its use through the forecasting of hurricanes.

In the healthcare arena, federal investigators have moved away from the “pay-and-chase” model and have added predictive analytics to their tool kit to detect healthcare fraud. The system uses algorithms and models to examine Medicare claims in real time to flag suspicious billing patterns. This has cut down significantly on the amount of money lost.

Last month, The Centers for Medicare and Medicaid released a report outlining how it saved $42 billion as a result of its program integrity efforts. From October 1, 2012 through September 30, 2014 every dollar invested in CMS’ Medicare program integrity efforts saved $12.40 for the Medicare program, according to the agency. It plans to release 2015 numbers later this year.

Those who are not purposely engaging in healthcare fraud may ask why should I care? This doesn’t impact me. But you would be wrong. You don’t have to intentionally engage in fraudulent practices for investigators to come knocking at your door. Sometimes even the most legitimate claims appear as outliers that can trigger an audit or investigation.

Regardless of whether you are a solo practitioner or head up an entire healthcare system, a compliance program needs to be in place to ensure that there is proper monitoring and tracking of billing and claims information.

If you don’t have a process in place, or haven’t looked at your processes in a while, now is the time. Even more important is to make sure it’s actually working, and if it’s not, determine what needs to be done to ensure that it is.

Just last month, the U.S. Department of Justice, in announcing that three South Floridians had been charged in a $1 billion Medicare fraud and money laundering scheme, credited its use of predictive analytics in making the arrests.

“The FBI and HHS-OIG ultimately employed advanced data analysis and forensic accounting techniques and were able to identify the full scope of the fraud scheme,” the DOJ wrote in a news release.

In that case, the owner of more than 30 Miami-area skilled nursing and assisted living facilities, a hospital administrator and a physician’s assistant were charged with conspiracy, obstruction, money laundering and healthcare fraud in connection with a $1 billion scheme involving numerous Miami-based healthcare providers.

Since its inception in 2007, the Medicare Fraud Strike Force, which operates in nine locations across the country, has charged nearly 2,900 defendants who have collectively billed the Medicare program for more than $10 billion.

There are a number of steps you can take to ensure that your billing practices don’t trigger an audit or investigation. The Healthcare Offices of Anthony C. Vitale may be able to assist you. If you have any questions or concerns, feel free to contact The Health Law Offices of Anthony C. Vitale at 305-358-4500 or email us at

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