The June 2010 conviction of a doctor and his wife who were illegally dispensing prescription drugs to unsuspecting patients through their “pain management clinic” in Kansas put an end to a health care fraud scheme that had devastating consequences. While the fraudsters collected more than $4 million from 93 different private health insurance and government health care programs, they were also responsible for more than 100 overdoses and at least 68 deaths.
Health care fraud is a multi-billion dollar problem with implications that go way beyond the financial damage it inflicts upon the system and its victims. The billions in losses are compounded by the side effects that manifest in the sometimes devastating toll it takes on human health and life. According to the FBI’s Financial Crimes Report, one of the most significant trends observed recently includes the willingness of medical fraudsters to risk patient harm in their schemes by performing unnecessary surgeries, prescribing dangerous drugs and providing sub-standard care.
Preventing Fraud Before it Happens
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“Health care fraud has always been a problem,” says Beth Bernardo, Product Specialist, Risk, Fraud and Investigations, at Thomson Reuters. “However in recent years it’s been gaining more attention and there’s been a lot more of an effort to really try to curb this fraud, particularly preventing the fraud at the front end, before it happens, as opposed to investigating it after it’s happened and then going out and recovering funds.”
How It Works
CLEAR for Healthcare Fraud uses industry data and key provider content such as NPI (National Provider Identifier) numbers, sanctions data and professional licensing information, to conduct a deep search of utility records, cell phone data and other public records. The tool finds not just minor data aberrations, but real inconsistencies to flag for investigation. The results of those investigations can help to find fraudulent healthcare providers and save Medicare and Medicaid billions of dollars.
“Our goal is to assist government, corporate healthcare and insurance in combating the multi-billion dollar fraud problem,” says Bernardo. “We want to make it easier for investigators to find the right information by providing a one-stop shop.” The online record search platform reaches across tens of millions of public records and delivers aggregated results that provide a meaningful look into the subject of the investigation.
There are three ways it works, explains Bernardo:
1. During the enrollment process it can find information that might indicate past or possible future fraudulent behavior, including activities in a different state.
2. Data in the system is used as a complement to some of the more traditional data mining techniques, such as looking for aberrations in claims patterns, and that might indicate fraudulent billing.
3. Once you find that you have a provider you think might be fraudulent it provides the full picture of the subject under investigation.
A Deeper Search Gets Detailed Results
CLEAR’s deep web search tool can also bring red-flagged results, such as previous fraud or sanctions, to the top of the search results. “We classify results to make it more time-effective for the investigator and we also do a deep web search to search blogs and social sites that might be missed during a traditional web search,” says Bernardo.
The enormous costs of health care fraud are borne by everyone. Whether people have a private policy or pay taxes to fund public programs, health care fraud inevitably translates into higher premiums and out-of-pocket expenses for consumers, and reduced benefits or coverage. Add to that the dire human consequences and the need for drastic measures to combat this becomes painfully evident.