According to Centers for Medicare & Medicaid (CMS/ Medicare & Medicaid), Medicare & Medicaid fraud is adding up to $60 Billion annually. This alarming figure has caught the attention of those in the Healthcare industry including both Health Plans (Private/Public) & Healthcare Providers.

The following is a list of common fraud techniques that are used by healthcare providers:

• Providers billing for services not provided.

• Providers administering (more) tests and treatments or providing equipments that are not medically necessary.

• Providers administering more expensive tests and equipments (up-coding).

• Providers multiple-billing for services rendered.

• Providers unbundling or billing separately for laboratory tests performed together to get higher reimbursements.

• Providers charging more than peers for the same services.

• Providers conducting medically unrelated procedures and services.

• Policy holders traveling long distance for treatment which may be available nearby. (Possibly scams by bogus providers.)

• Policy holders letting others use their healthcare cards

So, why is this happening so rapidly?

The healthcare industry has undergone massive transformations with breakthroughs like the adoption of electronic medical record (EMR) solutions from Epic & Cerner, remote patient care and data-driven care. While these changes have created a more efficient health care system, improved patient outcomes, and boosted bottom lines, they have also given rise to a host of challenges such as fraud and security.

For healthcare organizations tasked with the responsibility to protect patient details and medical information as well as to ahear to all HIPPA guidlines data is their best friend and worse enemy. With the healthcare security landscapes and compliance requirements constantly evolving, organizations must be able to act quickly. And doing so, requires unlocking trends, patterns, and outliers buried in both structured and unstructured types of data. Collecting, preparing, and analyzing this fragmented data is no small feat, but with the help of sophisticated data analytics, it’s possible. Purpose built healthcare analytics is the most powerful weapon in this fight because it allows organizations to combine, integrate, and analyze all of their data at once — regardless of source, type, size, or format — and identify patterns needed to address fraud.

DataHub Analytics Framework For Healthcare 

Getting Started

 DataHub is committed to helping fight fraud in the healthcare space. The following table can help give you some ideas as to how to start your analytics projects.

DataHub is actively working with Healthcare companies both on the payer and provider side. For more information as to how DataHub can help you get started on your analytics journey, please contact us at This email address is being protected from spambots. You need JavaScript enabled to view it.