Data Mining: A new weapon in the fight against Medicaid fraud

On Friday July 16, US Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sibelius arrived in Miami to announce that 94 people had been charged with defrauding Medicaid, the US government’s health system. As the announcement was being made, 36 people had been arrested. In the city of Miami alone, 24 defendants were charged for their alleged participation in submitting false Medicare claims amounting to $103 million.

On Friday July 16, US Attorney General Eric Holder and Secretary of Health and Human Services Kathleen Sibelius arrived in Miami to announce that 94 people had been charged with defrauding Medicaid, the US government’s health system. As the announcement was being made, 36 people had been arrested. In the city of Miami alone, 24 defendants were charged for their alleged participation in submitting false Medicare claims amounting to $103 million.

A day before the announcement, the Florida Attorney General’s Office presented a letter to the Centers for Medicare and Medicaid Control requesting a Federal waiver that will allow them to conduct data mining operations in order to curb Medicaid fraud. The Florida Attorney General already operates a Medicaid Fraud Control Unit (MFCU). Normally this unit would not be allowed to access information collected by Medicaid in order to perform data mining, even if it’s for the purpose of fighting fraud. Secretary Sibelius has approved Florida’s request and hopes to see a pilot program beginning in that state on January 1st, 2011.

The measure will allow Florida’s MFCU to access data contained in the Medicaid Management Information System (MMIS). The MFCU can then utilize statistical models, complex algorithms, and pattern recognition programs to detect possible fraudulent or abusive practices. The waiver also allows the analysis of billing patterns by medical facilities that treat patients insured by Medicaid and Medicare.

Data mining is already used to uncover fraudulent billing and other irregularities in the Medicaid system. The national Medicare-Medicaid Data Match program compares the coding systems of Medicare and Medicaid in order to detect vulnerabilities in the billing and payment processes. The Florida waiver will allow deeper probing of data to discover fraudulent patterns.

Guest post by James Mowery. 

James is a computer geek that writes about technology and related topics. To read more blog posts by him, go to laptop computers.