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 multiple-billing for services rendered.
- Providers administering more expensive tests and equipment (up-coding).
- Providers charging more than peers for the same services.
- Providers conducting medically unrelated procedures and services.
- 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 online health records, 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.
For healthcare organizations tasked with the responsibility to protect patient details and medical information, 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. 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
DataHub is committed to helping fight fraud in the heathcare space. The following table can help give you some ideas as to how to start your analytics projects.