For the 'bounty hunter' of Medicare fraud, cases begin with analytics
Most fraud cases work like this: A whistleblower files a lawsuit or a tip, and investigators scour claims data to support the accusation. However, one personal injury attorney is finding success by working backward, according to Wired.
Known as the "bounty hunter" for Medicare fraud, John Mininno relies on data analytics to identify potentially fraudulent billing patterns. Then he seeks out former employees to verify the claims, offering to split the 15 to 30 percent whistleblower reward offered by the government.
This approach began when the Centers for Medicare & Medicaid Services (CMS) started to release physician payment data. Mininno saw an opportunity to undercut the time-consuming and expensive work law firms undertake to vet a whistleblower's fraud claim and, with the help of an angel investor, he formed the National Healthcare Analysis Group.
He uses analytics to scour Medicare billing data, looking for certain variables, such as providers that bill for patients who never seem to get better, clustered claims bunched around payment thresholds, or consistent billing during snowstorms, when patients often cancel appointments. Then he uses a database with the employment history of 70,000 healthcare workers to track down potential whistleblowers, usually employees who have worked at company or clinic for just a few months--a sign they may have seen corrupt behavior, but were unsure how to report it.
In one instance, Mininno uncovered a home health scheme by getting the company's IT administrator to hand over billing data that showed patterns of deliberate fraud in which the majority of claims hovered around Medicare's payment thresholds. That case is still being settled, but since 2012, Mininno has filed roughly 40 lawsuits, according to Wired.
Data analytics has made a push into the healthcare fraud industry, with more federal and state officials relying on analytics to uncover large-scale schemes. Some private insurers have discovered sophisticated fraud schemes using a model-based approach that highlights utilization anomalies. Still, some argue that the government relies too heavily on a pay-and-chase approach to fraud, and rather than denying claims, CMS has saddled investigators with more fraud investigations.
To learn more:
- read the Wired article
Medicare doc data reveals million-dollar earners
It's not perfect, but Medicare payment data a jumping-off point for fraud detection
Feds, states turning to predictive analytics to prevent fraud
Why Big Data still isn't putting a dent in Medicare fraud
Data analytics detect fraud schemes in Florida
Predictive analytics helps fraud fighters detect sophisticated schemes [Special Report]