Immediate, real-time access to medical claims data could bolster federal efforts to crack down on health care fraud, the Wall Street Journal reports.
The federal government’s multi-agency Health Care Fraud Prevention and Enforcement Action Teams, or HEAT, have achieved some success in using data-mining techniques to identify fraud cases.
About 285 investigators in HHS’ Office of the Inspector General have direct access to a system allowing them to access claims data that is one to two months old. Still, only a limited number of federal fraud investigators have immediate access to real-time claims data.
Strategies for Improving Fraud Detection
Gerald Roy, HHS’ deputy inspector general for investigations, said “We are indeed in our infancy stages here — we have a long way to go until we are wholly data-driven.”
Roy said he is working to facilitate access to claims data that are no more than 24 hours old and would like to establish centers for investigators to analyze the data. He said he hopes to enable fraud investigators to detect suspicious billing patterns earlier so Medicare can halt payments immediately (Schoofs/Tamman [1], Wall Street Journal, 12/22).
Peter Budetti, head of CMS’ new antifraud branch, said he aims to model Medicare fraud detection after the credit card industry, which uses sophisticated software tools to flag suspicious charges before issuing payments.
In addition, some law-enforcement officials have suggested that the federal government should publicly release de-identified billing data to deter health care fraud and abuse (Schoofs/Tamman [2], Wall Street Journal, 12/22).
Source: iHealthBeat
