Data Analytics, Data Sharing Help Combat Fraud at Health Agencies

Federal agencies are using their investments in data analytics and artificial intelligence to better prevent fraud and other financial crimes.

Speaking at the Federal News Network Staying Ahead of Fraud, Waste and Abuse seminar, representatives from Veterans Affairs, Centers for Medicare & Medicaid Services (CMS), and HHS outlined how their agencies are reducing abuse of their services through more sophisticated forms of detection.

The movement of financial aid and other services to digital platforms left these agencies with many exploitable vulnerabilities. The amount of transactions and recipients managed by these organizations is often immense, creating a corresponding demand to more effectively review their services for illicit or wasteful use.

“Under Medicare, there are approximately 1.2 billion claims submitted per year. In addition, we at the Centers for Medicare and Medicaid Services in particular enroll 239,000 providers a year,” said Dara Corrigan, CMS Director of the Center for Program Integrity, during the FNN seminar.

One obstacle toward more effective fraud detection and prevention is human capital, specifically the amount of work that goes into manually reviewing records and transactions to note any suspicious behavior.

“What we’re always trying to do with our data analytics is to have the most correct and accurate data in the same place at the same time so that we can be using algorithms and analytics to try and see where the fraud is going or where it might be starting… What we’re trying to do when we’re preventing is to look for trends and to share trends with insurers so that we can catch the fraud in the quickest possible way,” Corrigan said.

Using data analytics to better detect unusual behavior and identify bad actors has led to collaboration between agencies with similar goals, such as VA and CMS adopting new anti-fraud techniques and sharing knowledge on best practices. VA has focused on adapting these practices over the past three years in part to prevent fraudulent activity as it expands its community care programs.

“We have formed a task force with the Department of Justice, the Veterans Affairs Healthcare Fraud Task Force, which we started in October of 2019,” said David Johnson, VA Assistant Inspector General for Investigations, during the FNN seminar. “That is partnering with the strike forces that CMS and HHS OIG have already established and have a great track record. One of the things that I’ve wanted to emulate over at VA is the robust data analytical programs that the [Medicare Fraud] Strike Force has used to detect potential fraud and try to use them in our growing community care programs.”

The move toward managing services through online portals during the COVID-19 pandemic increased fraud opportunities, prompting agencies to further refine their approach to detection and mitigate a recent surge in identify theft.

“COVID-19 and pandemic-related fraud schemes have taken center stage for HHS OIG,” said Miranda Bennett, HHS Assistant Inspector General for Investigations, during the FNN seminar. “Those schemes have shifted throughout the courses in pandemic where we first saw advertisements for fake treatments and cures. Then they shifted to fake vaccination card schemes, and then now they’re setting up a fake COVID-19 testing centers which are really meant to get ahold of personal identifying information that can be used to submit fraudulent claims to programs.”