[Video] Implementing Analytics to Reduce Fraud, Waste and Abuse
Mike Hostetler, HMS Vice President for Program Integrity
Steve Shandy, Director, Consolidated Data Analysis Center(CDAC), DHHS
Aaron Bird, General Manager, Insight Analytics Adobe Systems.
transcription of a video recorded June 19, 2012
Mike Hostetler, HMS VP of Program Integrity begins his presentation by posing a question to the audience: “What do fraud and abuse look like?” He then continues his inquiry by asking how healthcare IT systems are designed in the wake of the Affordable Care Act. Hostetler reports that HMS has assisted in the recovery of $2.8 billion for clients, from overpayment. 2 billion claims per year are processed through HMS.
Hostetler elaborates on the difficulties of detecting fraud. He reports on the rising usage of predictive analytics and the need to adapt as fraud schemes change. Hostetler then questions what fraud, waste, and abuse might look like in an accountable care organization. He reports that “big data” is happening now and inquires how it can be leveraged to prevent fraud, waste, and abuse.
Hostetler stresses the need to bring program integrity department “into the mix” before the application and payment process begins. In closing, he highlights the need for transparency of data access.
Next, Steve Shandy is introduced from the office of the Inspector General of the Department of Health and Human Services. Shandy begins by emphasizing the need to protect healthcare programs and beneficiaries. Shandy’s task force targets fraud, waste, and abuse through enforcement and preventative measures.
“Let the data tell us where the problems are,” says Shandy, before he displays a map showing core-based statistical areas across the United States. The map shows where payments of Medicare and Medicaid exceed three times the national average.
Shandy then discusses the coordination of efforts between HHS and the Department of Justice to investigate higher claims and research payment trends. He then utilizes the city of Miami, Florida as an example of an area of ongoing billing concerns and elaborates on a particular case of a doctor who perpetrated fraud using Medicare outlier billing, to the final figure of $350 million.
Shandy concludes by thanking Rob Waters of Healthcare IT Connect.
The next and final speaker is Aaron Bird, from Adobe Systems. Bird address the changes in the world due to digital experiences and discusses the efforts of Adobe beyond the Creative Suite programs (Photoshop, Illustrator, etc). Adobe’s current focus lies in creation, engagement, efficiency, and measurement, according to Bird.
Bird then gives a brief example of workflow routing and digital rights management via Adobe LiveCycle. He then presents Adobe’s Real-Time Consumer/Citizen Event Behavior Analysis visualization. Bird remarks “Understanding behavior is the key tenet to understanding fraud behavior.”
Bird underlines the applications of Adobe in healthcare by exploring the nature of consumer analysis (i.e. web interactions). Bird states: “If you can’t digitize the information, you can’t analyze the information.” He continues by highlighting the need for data discovery and the idea of digitizing the explanation of benefits form that healthcare providers utilize for enrollment.
Bird concludes his presentation and the attendees ask questions of the speakers.