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5 Things Your Fraud Unit NeedsTo Do

by Richard Lynch, on May 1, 2017 10:08:35 AM

Spot.pngIn the recent blog The War on Healthcare Fraud , our colleague made the case that the Health plans and Government Health agencies will never win the war “one tip at a time.” Something dramatically different is needed.

The current investigation process is like a person looking for his car keys under a spotlight. When the policeman asks where do you think you lost them, the man points to over in the shadows. To which the policeman fires back, “Then why are you looking here?” The man looks up and says “That’s where the light is.”

While a spotlight is useful at illuminating what it’s pointing at, it needs to be moved manually to shine on other areas.

Here’s where Artificial Intelligence and Machine Learning comes in — it shines the light on the shadows. New powerful tools are available to the fraud investigator that he never had access to before. These tools, such as Absolute Insight, offer a simplified approach to data sets, coupled with powerful analytics and data visualization for insights. However, to take advantage of these powerful tools, the Fraud Unit needs to upgrade its business process, skills, and best practices.

Here five things they should be doing now:

  1. Look at the entire  data set to analyze the information. If you are only looking at samples, you’ll only find what’s under the spotlight. Big data encompasses the totality of information, rather than the bits and pieces featured in samples.
  2. Cross reference the data set with other databases. Big Data is a somewhat misleading term. Rather than thinking about it in terms of size, its strength is about the capacity to search, aggregate, and cross-reference large data sets. 
  3. Start real-time monitoring of changes over time. Data isn’t static. Monitoring changes over time will allow you notice patterns, make predictions, and take action at a time when it will make the strongest impact.
  4. Focus on targeted audience (high risk) and audit them. While fraudulent behavior, waste, and abuse takes on many forms, “soft” targets are the best places to start looking. Consolidate your efforts here to capture the low hanging fruit before shifting your efforts elsewhere. 
  5. Get  alerts once changes occur. The atmosphere in which data lives is constantly changing. Investigators need to keep up with the changes, whether they’re regulatory, departmental, or practice based.

Fraud Units need to start incorporating these strategies. Along with the powerful capabilities offered by AI and Machine Learning, those responsible will also need to streamline the investigation process and harvest and monitor the benefits identified by predictive analytics.  

 Note: This blog came from an interview with Kleber Gallardo, CEO  of Alivia Analytics

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