How data mining is uncovering healthcare fraud

healthcare fraudWhat does your data say about your healthcare practice? Does it show that you bill considerably more than your colleagues for certain types of procedures? What about your facility? Is it performing more of a particular procedure than nearby competitors?

These days, healthcare fraud investigators increasingly rely on data to root out healthcare fraud. They are using the data that is being mined by federal and state agencies such as Medicare and Medicaid (and even private insurers) to identify providers who might be considered outliers.

Because auditing all claims is not feasible or practical, investigations are based on what is known as predictive analytics. In 2011, the Centers for Medicare and Medicaid started running all Medicare fee-for-service claims through a set of predictive algorithms before paying them, in an effort to ferret out healthcare fraud and abuse.

In July, CMS announced that it had identified or prevented $820 million in inappropriate payments over the past three years through its Fraud Prevention System. That system uses predictive analytics to identify questionable billing patterns in real time, as well as review past patterns that might indicate fraud.

With the increasing use of data mining to detect fraud and abuse, providers today can become the target of scrutiny simply based on the amount of medical services billed.

In November, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released an 80-page Work Plan for FY 2016. In that report, it outlined the areas where it will be looking for questionable billing patterns. Among some highlights:

Medicare oversight of provider-based status: The OIG will determine the number of provider-based facilities that hospitals own and the extent to which CMS can oversee provider-based billing. The OIG noted that The Medicare Payment Advisory Commission (MedPAC), has expressed concerns about the financial incentives presented by provider-based status and stated that Medicare should seek to pay similar amounts for similar services.

Comparison of provider-based and freestanding clinics: The OIG will review and compare Medicare payments for physician office visits in provider-based clinics and freestanding clinics to determine the difference in payments made to the clinics for similar procedures and assess the potential impact on Medicare of hospitals’ claiming provider-based status for such facilities.

Selected inpatient and outpatient billing requirements: The OIG will review Medicare payments to acute care hospitals to determine hospitals’ compliance with selected billing requirements and recommend recovery of overpayments. Previous OIG audits, investigations, and inspections have identified areas at risk for noncompliance with Medicare billing requirements.

Outpatient dental claims: The OIG will review Medicare hospital outpatient payments for dental services to determine whether such payments were made in accordance with Medicare requirements. OIG audits have found that hospitals received Medicare reimbursement for non-covered dental services, resulting in significant overpayments.

Medicare payments during MS-DRG payment window: The OIG will review Medicare payments to acute care hospitals to determine whether certain outpatient claims billed to Medicare Part B for services provided during inpatient stays were allowable and in accordance with the inpatient prospective payment system. Previous OIG audits, investigations and inspections have identified this area as being at risk for noncompliance with Medicare billing requirements.

Skilled nursing facility prospective payment system requirements: The OIG will review compliance with various aspects of the skilled nursing facility (SNF) prospective payment system, including the documentation requirement in support of the claims paid by Medicare. Prior OIG reviews have found that Medicare payments for therapy greatly exceeded SNF’s cost for therapy.

Home health prospective payment system requirements: The OIG will review compliance with various aspects of the home health prospective payment system (PPS), including the documentation required in support of the claims paid by Medicare. It will determine whether home health claims were paid in accordance with federal laws and regulations. A prior OIG report found that one-in-four home health agencies had questionable billing.

This is just a small selection of some of the ways that regulators are looking at data to determine whether healthcare fraud is taking place. A full list can be found here.

As we enter 2016, healthcare providers would be wise to conduct their own audits in order to understand what it says about their billing practices. It could help to find patterns that could trigger a fraud investigation and allow you to head off any problems in the future.

The Health Law Offices of Anthony C. Vitale can assist you in these matters. Give us a call and let us know how we can help you.

Material presented on the Health Law Offices of Anthony C. Vitale's website is intended for information purposes only.

It is not intended as professional advice and should not be construed as such.