Posted by Douglas Wood, Editor.
The National Association for Medicaid Program Integrity (NAMPI) wrapped up its 31st annual conference yesterday (August 12) in New Orleans with the theme “Jazzing up Program Integrity in the Big Easy.” I’m glad that the conference itself was full of cool presentations and networking events, because the temperature outside was Hot Hot Hot! (Note to self: One ‘Hurricane’ at Pat O’Briens on Bourbon Street is enough.)
50 years after President Lyndon Johnson signed into law legislation creating two new national health insurance programs – Medicare and Medicaid – the latter is the largest source of medical and health-related services in the US, providing healthcare to over 68 million Americans with a low income. As the number of enrollees continues to grow, so then does the challenge of maintaining program integrity and fighting the inevitable fraud that hurts us all.
As someone who markets technology solutions in the fight against fraud and crime, I found much of the conference to be right up my alley. As with any conference, much of the agenda was sponsored by vendors of data solutions and technology. Kudos to LexisNexis for sponsoring keynote speaker Elizabeth Smart, former kidnapping victim and advocate for children’s safety. Her story was a powerful way to begin the conference and the packed room was riveted by her story and courage.
NAMPI president John McCormick’s Monday morning remarks were short and sweet and set the tone for what turned out to be an excellent couple of days. In particular, I thought the breakout session on program integrity by the US Government Accountability Office was excellent, as well as a session discussing the facts and myths about Return on Investment. The panel included Illinois Inspector General Brad Hart, Ohio’s Lalita Jambhale, and Oklahoma’s Cindy Roberts. A session called Advanced Analytics was also well-attended and, in my opinion, one of the better forums.
There were several excellent vendor-specific sessions as well, most notably a session entitled “The Next Generation of Medicaid Program Integrity: Where Identity Data, Linking Technology, and Clearing Houses Intersect”, and a look at Missouri’s Medicaid Audit and Compliance programs sponsored by Truven Analytics.
A walk around the Exhibitor floor showed most of the usual suspects – HMS, Truven, SAS, IBM, and others. Each vendor had some uniqueness and most had interesting fraud detection and visual analytics. Still missing from the end-to-end solution equation, however, is an investigative case management system that is purpose designed for Medicaid fraud investigations. Most vendors talked a good talk… few could walk the walk in that area. And what about a biometrics play? Identity assurance is a key element to medical care, why not in program integrity? When will someone fill those voids?
Of note, 21CT was in attendance and had, from what I could see, one of the better overall demonstrations. Their Torch offering continues to impress. Also interesting, Appriss‘ continued push into the industry with their ever-growing database of incarceration records. All vendors performed well, and a full list of those sponsors and exhibitors can be found on the NAMPI Conference website.
Congratulations to NAMPI on an excellent conference, and here’s hoping that the ideas shared continue to put a dent in the billions lost to fraud each year.
Tag Archives: 21ct
Using Link Analysis to untangle fraud webs
Posted by Douglas Wood, Editor.
NOTE: This article originally appeared HERE by Jane Antonio. I think it’s a great read…
Link analysis has become an important technique for discovering hidden relationships involved in healthcare fraud. An excellent online source, FierceHealthPayer:AntiFraud, recently spoke to Vincent Boyd Bryant about the value of this tool for payer special investigations units.
A former biometric scientist for the U.S. Department of Defense, Bryant has 30 years of experience in law enforcement and intelligence analysis. He’s an internationally-experienced investigations and forensics expert who’s worked for a leading health insurer on government business fraud and abuse cases.
How does interactive link analysis help insurers prevent healthcare fraud? Can you share an example of how the tool works?
Boyd Bryant: Link analysis is most often used to piece together different kinds of data from multiple sources–to identify key players, connections between those players and patterns of behavior frequently missed. It can simplify an understanding of the level of involvement of individuals and criminal organizational hierarchies and can greatly simplify visualizing and communicating the operations of complex criminal enterprises.
One thing criminals do best is hide pots of money in different places. As a small criminal operation becomes successful, it will often expand its revenue streams through associated businesses. Link analysis is about trying to figure out where all those different baskets of revenue may be. Insurers are drowning in a sea of theft. Here’s where link analysis becomes beneficial. Once insurers discover a small basket of money lost to a criminal enterprise, then serious research needs to go into finding out who owns the company, who they’re associated with, what kinds of business they’re doing and if there are claims associated with it.
You may find a clinic, for example, connected to and working near a pharmacy, a medical equipment supplier, a home healthcare services provider and a construction company. Diving into those companies and what they do, you find that they’re serving older patients for whom multiple claims from many providers exist. The construction company may be building wheelchair ramps on homes. And you may find that the providers are claiming payment for dead people. Overall, using this tool requires significant curiosity and a willingness to look beyond the obvious.
Any investigation consists of aggregating facts, generating impressions and creating a theory about what happened. Then you work to confirm or disconfirm your theory. It’s important to have tools that let you take large masses of facts and visualize them in ways that cue you to look closer.
Let’s say you investigate a large medical practice and interview “Doctor Jones.” The day after the interview, you learn through link analysis that he transferred $11 million from his primary bank account to the Cayman Islands. And in looking at Dr. Jones’ phone records, you see he called six people, each of whom was the head of another individual practice on whose board Dr. Jones sits. Now the investigation expands, since the timing of those phone calls was contemporaneous to the money taking flight.
Why are tight clusters of similar entities possible indicators of fraud, waste or abuse?
Bryant: When you find a business engaged in dishonest practices and see its different relationships with providers working out of the same building, this gives rise to reasonable suspicion. The case merits a closer look. Examining claims and talking to members served by those companies will give you an indication of how legitimate the operation is.
What are the advantages of link analysis to payer special investigation units, and how are SIUs using its results?
Bryant: Link analysis can define relationships through data insurers haven’t always had, data that traditionally belonged to law enforcement.
Link analysis results in a visual reference that can take many forms: It can look like a family tree, an organizational chart or a time line. This reference helps investigators assess large masses of data for clustering and helps them arrive at a conclusion more rapidly.
Using link analysis, an investigator can dump in large amounts of data–such as patient lists from multiple practices–and see who’s serving the same patient. This can identify those who doctor shop for pain medication, for example. Link analysis can chart where this person was and when, showing the total amount of medication prescribed and giving you an idea of how the person is operating.
What types of data does link analysis integrate?
Bryant: Any type of data that can be sorted and tied together can be loaded into the tool. Examples include telephone records, addresses, vehicle information, corporate records that list individuals serving on boards and banking and financial information. Larger supporting documents can be loaded and linked to the charts, making cases easier to present to a jury.
Linked analysis can pull in data from state government agencies, county tax records or police records from state departments of correction and make those available in one bucket. In most cases, this is more efficient than the hours of labor needed to dig up these types of public records through site visits.
Is there anything else payers should know about link analysis that wasn’t covered in the above questions?
Bryant: The critical thing is remembering that you don’t know what you don’t know. If a provider or member is stealing from the plan in what looks like dribs and drabs, insurers may never discover the true extent of the losses. But if–as a part of any fraud allegation that arises–you look at what and who is associated with the subject of the complaint, what started as a $100,000 questionable claims allegation can expose millions of dollars in inappropriate billings spread across different entities.