Fraud – it’s something we like to pretend doesn’t happen and can’t affect our data management, but the reality is that everyone is at risk. Cells of individuals have popped up throughout the world, focused solely on hacking systems, stealing information and making a quick profit. It’s created a whole industry for cybersecurity and standards for information protection.
While it makes sense that people would want to steal your financial information, there are other areas that tend to attract hackers, including medical records. In that case, the fraudulent individuals are not seeking to duplicate your strep throat or mimic your latest physical. Instead, they are looking for ways to defraud the government and get paid on procedures or services that they never completed or provided – and it’s big business.
According to a post in Health Data Management, a predictive analytics system has successfully increased the recovery and prevention of improper Medicare payments. Throughout the healthcare system, improper Medicare claims are made on a regular basis. In some cases, the claims are the result of improper paperwork or miscoding of a procedure – an oversight and not outright fraud.
In other cases, however, providers are seeking to take advantage of a crowded system, hoping to get paid on procedures through a process that is difficult to manage and therefore difficult to identify false claims. The Small Business Jobs Act of 2010 allowed for the use of predictive modeling by the Department of Health and Human Services to identify these improper claims. In using this technology for data management, the Fraud Prevention System (FPS) in its first three years of operation has identified or prevented as much as $820 million in payments deemed inappropriate according to Medicare guidelines.
While auditors have certified only $133 million in adjusted savings, the point shows the Department’s improved approach to data management, understanding the threat of fraudulent activities and putting the right tools in place for prevention. In their report, auditors do suggest that the Department improve written directives to contractors to ensure the proper identification and reporting of accurate savings. Such directives should include improved instructions on how to attribute proper savings, as well as optimal data management to reflect accurate numbers.
The attraction to inefficient systems for quick cash is irresistible for those that hack into systems for a living. When processes are ill-equipped to identify fraudulent activity or network security can’t detect a breach by those who shouldn’t have access to the system, theft and loss will occur. In healthcare, much attention is placed on privacy and the application of HIPAA to protect personal information. The same level of care should be applied to the management of payments to ensure only legitimate procedures are approved and paid.