Data Analytics Aids Largest Health Care Fraud Takedown

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Attorney General Loretta E. Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell this week announced an anti-fraud task force led by the Justice and Health and Human Services Departments executed the largest takedown of health care fraud in U.S. history, charging 301 individuals in 36 Federal districts for health care schemes equaling $900 million.

“The diligent use of innovative data analytic systems has contributed or led directly to many of the law enforcement cases presented here today,” said Shantanu Agrawal, the deputy administrator and director of Centers for Medicare and Medicaid Services (CMS) Center for Program Integrity. “CMS is committed to its collaboration with these agencies to keep federally funded health care programs safe and strong for all Americans.”

According to court documents, charges included various health care fraud-related crimes, including conspiracy to commit health care fraud, violations of the anti-kickback statutes, money laundering, and aggravated identity theft. The charges are based on several alleged fraud schemes involving various medical treatments and services, including home health care, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and prescription drugs.

More than 60 of the defendants were charged with fraud related to the Medicare prescription drug benefit program known as Part D, which is the fastest growing component of the Medicare program overall.

“I think the thing that really is different is the speed with which we are able to do our jobs,” Ann Maxwell of the Office of the Inspector General at the U.S. Department of Health and Human Services told MarketPlace.

Maxwell also noted the team has gained access to real time data for Medicare and Medicaid in the last five years.

In August 2015, MeriTalk conducted a study, underwritten by MarkLogic, called The Economics of Eligibility: The Cost of Eligibility and Verification Challenges for Government Healthcare Benefits. The study examined health and human services agencies’ pain points, and revealed these agencies are struggling to balance rising benefits enrollment with a variety of eligibility and verification challenges.

Most notably, the study stated $342 billion is lost each year due to improper payments from benefit eligibility and verification issues, with case workers estimating 11 percent of current beneficiaries should not be receiving benefits.

According to MarketPlace, the Federal government estimates it loses 12 percent of Medicare spending and about 10 percent of Medicaid to fraud and other improper payments. Last year, the government lost more than $70 billion.

Now, these agencies are ramping up and focusing more on data: The Department of Health and Human Services hired a chief data officer this year and is planning to hire 10 additional staff members for that office.

Including Wednesday’s enforcement actions, the Justice Department states nearly 1,200 individuals have been charged in national takedown operations, which have involved more than $3.4 billion in fraudulent billings.

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