Sunday, August 7, 2011

Tech Helps to Cut Fraud

Lewis Morris, Chief Counsel, Office of Inspector General (OIG) at HHS, testified before the Senate Committee on Homeland Security and Government Affairs, Subcommittee on Federal Financial Management on July 12th. His topic “Harnessing Technology and Innovation to Cut Waste and Curb Fraud in Federal Health Programs” zeroed in on using technologies effectively to prevent fraud.

His testimony provided examples of how advanced data analytics can help conduct risk assessments, more effectively pinpoint the agencies oversight efforts, and significantly reduce the time and resources required for audits, investigations, and other program integrity activities.

For example, OIG’s data warehouse is a key component in using information technologies effectively to combat fraud. The warehouse integrates data from Medicare parts A, B, and D so that a more comprehensive picture is available on beneficiaries and their history of medical care along with providers’ billing patterns. For example, it is possible to flag Part D prescription drug claims when there is not a related physician or hospital claims under Parts A or B which may suggest possible fraud.

In the past, OIG’s hospital audits typically focused on specific areas of risks and claims and were audited exclusively related to that area. This resulted in the agency narrowly focusing audits because there were limits on the capacity to store and match data. Now with increased data storage, computer matching, and data analytic capabilities, the agency is able to efficiently analyze a vast array of hospital data to simultaneously identify multiple compliance risks. Today, the data can provide a comprehensive picture of how a hospital is performing and where compliance problems may exist by using computer matching and data mining techniques.

Medicare Fraud Strike Forces using sophisticated data analysis combined with field intelligence and traditional law enforcement techniques have made it possible to more quickly identify fraud schemes and trends. The data-driven approach of the Strike Force pinpoints fraud hot spots by identifying suspicious billing patterns and targets criminal behavior as it occurs.

OIG’s use of technology is also able to exclude individuals and entities from participating in Federal healthcare programs to prevent inappropriate payments being made to these individuals and entities. OIG posts its “List of Excluded Individuals and Entities” (LEIE) on the OIG web site, updates the list monthly, and the information is available on-line in searchable and downloadable formats.

OIG realizes that as program integrity efforts become more technology driven, so will fraud. For example, EHRs not only facilitate more accurate billing and increase quality of care, but at the same time, produces more fraudulent billing. EHRs have the ability to make a physician’s job easier but cut and paste features and templates can also be used to fabricate information resulting in improper payments.

In addition, OIG reports have identified significant vulnerabilities related to the security of electronic patient health information. It has also been found that many hospitals inadequately safeguard their wireless networks, leaving sensitive health information vulnerable to hacking.

In addition, HHS has not promulgated policies that would help ensure that adequate general IT controls exist to protect networks and computer systems containing EHRs. OIG recommends that HHS conduct compliance reviews to ensure that security rule controls are in place and operating to protect personal health information.

The challenge for OIG is to continue to ensure appropriate implementation and provide vigorous oversight of all of the new technologies that can help to cut waste and fraud in the Federal Healthcare programs. OIG realizes that there aren’t any simple solutions, since the growth of information technologies along with the ever increasing access to sensitive data will still produce evolving fraud risks, but with the appropriate use of today’s technologies, this risk can be greatly reduced.