Feds, states turning to predictive analytics to prevent fraud

The largest fraud bust in U.S. history probably wouldn't have happened without the assistance of data analytics, according to the chief data officer at the Office of Inspector General.

Analytics served as major tool in June's national fraud bust involving 243 people who were accused of falsely billing Medicare $712 million, which allowed Medicare Fraud Strike Force teams to pinpoint areas of the country with billing anomalies, Caryl Brzymialkiewicz, assistant inspector general and chief data officer at the OIG, told attendees of the Predictive Analytics World Conference in Washington, D.C., according to Federal News Radio.

In particular, analysts reviewed Medicare Part D claims for questionably high prescription drug claims, which contributed to 44 of the 243 arrests. Brzymialkiewicz, who has been on the job for six months, said she utilizes data scientists, as well as auditors, attorneys and law enforcement officials to uncover fraud schemes. Many of her new hires, who are millennials fresh out of college, are more adept at sifting through data, she says, which helps federal investigators identify the next developing scheme.

"We're trying to develop new approaches to identify unknown, undetected and emerging patterns," Bryzmialkiewicz said at the conference. "So that Whac-a-Mole pattern, how do we get ahead of that? How do we counter new and existing fraud, waste and abuse?"

States are also jumping headlong into predictive analytics to curb fraud, waste and abuse. Arkansas Gov. Asa Hutchinson announced last week that he has assembled a new Payment Integrity Unit within the Department of Human Services (DHS) and the Office of Medicaid Inspector General (OMIG). The new unit, which includes five new positions at DHS and two new positions at OMIG, plans to utilize data analytics to pinpoint areas of abuse.

The push toward predictive analytics has been evident in both the public and private sectors following years employing a "Whac-a-Mole" approach to fraud detection. Fraud experts have said that a strategic approach to data can help payers and the government identify irregular billing patterns, and investigators are pulling data from multiple commercial databases to bolster fraud investigations. Last month, a survey by the Medial Identity Fraud Alliance showed that 45 percent of survey respondents said their organization was spending more money on fraud prevention and mitigation tools.

For more:
- read the Federal News Radio article
- here's the Arkansas announcement

Related Articles:
Predictive analytics catch fraudulent claims
Former CMS administrator says fraud detection is better, but gaps remain
Survey: Healthcare invests more in medical identity fraud prevention, detection
To fight fraud, go in with the new, out with the Whac-a-Mole
Multiple commercial data sources bolster fraud investigations

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