Fraud Prevention – The Tip of the Iceberg

Andrew Froehlich, Network Engineer & IT Consultant | 2/29/2012 | 27 comments

Andrew Froehlich
The Department of Health and Human Services released its 2011 Health Care Fraud and Abuse Control Program report last week. In a press release, the department detailed how the federal government won or negotiated about $4.1 billion in healthcare fraud judgments and settlements.

That's a substantial amount of tax dollars, and it's great to see success stories such as this, which can help lower the overall cost of healthcare. In fact, it was far and away the most money that the HHS has ever recovered.

How did it become so good at cracking down on healthcare fraud perpetrators? There are hard-working individuals on "Medicare fraud strike force teams," but a great deal of credit must also go to the government's new Fraud Prevention System (FPS).

Just last year, the Centers for Medicare & Medicaid Services were allotted about $270 million in funding from the HHS and Congress to combat fraud and waste within the federal healthcare system. According to an annual report (PDF download), the CMS used a portion of the funds to "build on existing fraud prevention activities and implement new advanced technology to ensure that accurate payments are made to legitimate providers for appropriate and reasonable services for eligible beneficiaries of the federal health care programs." The FPS was born from this funding.

The system, which went live in June, uses the same predictive modeling technologies that credit card companies use today.

This is interesting, because it would seem that fraud prevention software has become easier to repurpose for varying types of data and predictive informaton. Previously, these systems were designed and built for a specific purpose, usually in the financial servies industry, but now they are much more flexible and can adapt to fit many different environments.

Much of the problem with implementing fraud prevention systems in other areas had to do with the fact that data was not always stored digitally. And even if it was, it was dispersed in multiple databases and in differing formats. But now that there is a push for digital medical record standards, all the data is beginning to line up, and that makes it very easy to wrap data mining and prediction analytics tools around it.

As a result, you can expect healthcare fraud to be exposed far more frequently in the future thanks to technology that was invented in the financial industry -- and reapplied for a slightly different purpose. Due to the apparent success of the FPS, I expect our government to apply similar systems to other areas where fraud is frequent. One obvious target would be the IRS, but perhaps a similar system has already been implemented, and we just haven't been told.

Just in case, you'd better make sure you have all your receipts for this year's tax season!

View Comments: Newest First | Oldest First | Threaded View
Page 1 / 3   >   >>
batye   Fraud Prevention – The Tip of the Iceberg   4/2/2012 1:54:16 AM
Re: Predict me this
I think we never get informed about a lot of the things what happens with our info at banks or other places, this days it just life... so to say
batye   Fraud Prevention – The Tip of the Iceberg   4/2/2012 1:52:12 AM
Re: Integration of data is key
yes, but in reality things not always perfect as we citizens would like them to be....
white.space   Fraud Prevention – The Tip of the Iceberg   3/31/2012 10:25:14 PM
Re: Predict me this
@Skr2011: Yes, can imagine. I am sorry it did not work out.
User Ranking: Blogger
Skr2011   Fraud Prevention – The Tip of the Iceberg   3/31/2012 9:36:47 PM
Re: Predict me this
@white.space The restaurant and lodge was a bit of a money pit but it was fun while it lasted.
Skr2011   Fraud Prevention – The Tip of the Iceberg   3/31/2012 9:19:45 PM
Re: Integration of data is key
@batye

I agree. Politics should not play a role, but what is the chance that a government commission would be apolitical;)
white.space   Fraud Prevention – The Tip of the Iceberg   3/31/2012 8:58:48 PM
Re: Predict me this
Thank you for sharing that story. And I absolutely agree with you, there is protection, and there is protection. I got an alert from a credit rating monitoring agency; and found that one of my credit cards was reported as lost or stolen. Now I still had that card on me, so concerned I call the bank. Turns out the card may have been compromised by an online merchant (who remained un-named), and the bank had decided to block the card, issue a replacement and notify the rating agencies. Noone thought me the customer, whose card was blocked, needed to be told. Till I found out the hard way. 

Btw, you owned a restaurant and lodge? Sounds lovely. Its something I would love to do at some stage.. 
User Ranking: Blogger
batye   Fraud Prevention – The Tip of the Iceberg   3/30/2012 2:35:19 PM
Re: Integration of data is key
as long as privacy commisioner would have people problems in mind

and work for a people...

as sometimes he/she like in few cases before have only gov. interest in mind and not citizens...
Skr2011   Fraud Prevention – The Tip of the Iceberg   3/30/2012 1:19:35 PM
Re: Integration of data is key
@bayte

I think the US can use a commission like that. Privacy has always been a tricky issue here because the founding fathers never spelled out privacy rights in the constitution. Lawyers today will tell you that the right to privacy was implied in the consitiution but who is out there really protecting our privacy in the US?
batye   Fraud Prevention – The Tip of the Iceberg   3/28/2012 3:30:35 PM
Re: Integration of data is key
 

http://www.priv.gc.ca/index_e.cfm

 

The Privacy Commissioner of Canada - legal position with a lot of the legal power to protect privacy rights

The Commissioner is an advocate for the privacy rights of Canadians and her powers include:
  • Investigating complaints, conducting audits and pursuing court action under two federal laws;
  • Publicly reporting on the personal information-handling practices of public and private sector organizations;
  • Supporting, undertaking and publishing research into privacy issues; and
  • Promoting public awareness and understanding of privacy issues.

 
Skr2011   Fraud Prevention – The Tip of the Iceberg   3/28/2012 12:25:55 PM
Re: Predict me this
@ white.space I owned a restaurant and lodge out in the middle of no where. More then once I experienced a guest whos bank had shut their card off because of the location and the fact that the guest had gased up at remote gas stations before making it to my place. There is protection and then there is over protection.
Page 1 / 3   >   >>


The blogs and comments posted on EnterpriseEfficiency.com do not reflect the views of TechWeb, EnterpriseEfficiency.com, or its sponsors. EnterpriseEfficiency.com, TechWeb, and its sponsors do not assume responsibility for any comments, claims, or opinions made by authors and bloggers. They are no substitute for your own research and should not be relied upon for trading or any other purpose.

More Blogs from Andrew Froehlich
Andrew Froehlich   4/16/2014   15 comments
With news that Google slashed the price of their big-data offering "Big Query" by up to 85 percent, one has to wonder if the move is to ward off competitors -- or simply that the ...
Andrew Froehlich   3/18/2014   26 comments
At a recent South By Southwest Interactive conference in Austin, Edward Snowden said the NSA is "setting fire to the future of the Internet." In light of this, the World Wide Web ...
Andrew Froehlich   2/28/2014   34 comments
An increasing number of partnerships, vendor contracts, and third-party agreements require opening access to your enterprise network. While offering access to these partners is usually ...
Andrew Froehlich   2/18/2014   10 comments
Annual IT security audits can be painful, yet they don't have to be.
Andrew Froehlich   2/11/2014   16 comments
Much of the focus around big data has been in electronic health records, customer data mining, and financial prediction models, but big data can be a big help in the field of IT security. ...
Latest Archived Broadcast
We talk with Bernard Golden about accelerating application delivery in the cloud.
On-demand Video with Chat
Register for this video discussion to learn how tablets can provide true business usability and productivity.
4/23/2014 - Dell Compellent performance and features make it an outstanding storage platform for SQL Server. Register for this webinar now.
E2 IT Migration Zones
IT Migration Zone - UK
Why PowerShell Is Important
Reduce the Windows 8 Footprint for VDI
Rethinking Storage Management
IT Migration Zone - FR
SQL Server : 240 To de mémoire flash pour votre data warehouse
Quand Office vient booster les revenus Cloud et Android de Microsoft
Windows Phone : Nokia veut davantage d'applications (et les utilisateurs aussi)
IT Migration Zone - DE
Cloud Computing: Warum Unternehmen trotz NSA auf die „private“ Wolke setzen sollten
Cloud Computing bleibt Wachstumsmarkt – Windows Azure ist Vorreiter
Like Us on Facebook
Twitter Feed
Enterprise Efficiency Twitter Feed
Site Moderators Wanted
Enterprise Efficiency is looking for engaged readers to moderate the message boards on this site. Engage in high-IQ conversations with IT industry leaders; earn kudos and perks. Interested? E-mail:
moderators@enterpriseefficiency.com
Dell's Efficiency Modeling Tool
The major problem facing the CIO is how to measure the effectiveness of the IT department. Learn how Dell’s Efficiency Modeling Tool gives the CIO two clear, powerful numbers: Efficiency Quotient and Impact Quotient. These numbers can be transforma¬tive not only to the department, but to the entire enterprise.

Read the full report
The State of Enterprise Efficiency in the Virtual Era: Virtualization – Smart Approaches to Maximize Gains
Virtualization is a presence in nearly all enterprise data centers. But not all companies are using it to its best effect. Learn the common characteristics of success, what barriers companies face, and how to get the most from your efforts.

Read the full report
Informed CIO: Dollars & Sense: Virtual Desktop Infrastructure
Cut through the VDI hype and get the full picture -- including ROI and the impact on your Data Center -- to make an informed decision about your virtual desktop infrastructure deployments.

Read the full report
SPONSORED BY DELL
CASE STUDIES
EBOOKS
PUBLIC SECTOR RESOURCES
VIDEOS
WHITE PAPERS
WINDOWS SERVER 2012 RESOURCES
A Video Case Study – Translational Genomics Research Institute
e2 Video


On the Case
TGen IT: Where We're Going Next

7|11|12   |   08:12   |   10 comments


Now that TGen has broken new ground in genomic research by using Dell's storage, cloud, and high-performance computing solutions, the company discusses what will come next for it and for personalized medicine.
On the Case
Better Care Through Better Communications

6|6|12   |   02:24   |   12 comments


The achievements of the TGen/Dell project could improve how all people receive healthcare, because they are creating ways to improve end-to-end communication of medical data.
On the Case
TGen IT: Where We Are Now

5|15|12   |   06:58   |   5 comments


TGen is breaking new ground in genomic research by using Dell's storage, cloud, and high-performance computing solutions.
On the Case
TGen IT: Where We Were

4|27|12   |   06:45   |   10 comments


The Translational Genomics Research Institute wanted to save lives, but its efforts were hobbled by immense computing challenges related to collecting, processing, sharing, and storing enormous amounts of data.
On the Case
1,200% Faster

4|18|12   |   02:27   |   12 comments


Through their partnership, Dell and TGen have increased the speed of TGen’s medical research by 1,200 percent.
On the Case
IT May Improve Children's Chances of Survival

4|17|12   |   02:12   |   8 comments


IT is helping medical researchers reach breakthroughs in a way and pace never seen before.
On the Case
Medical Advances in the Cloud

4|10|12   |   1:25   |   5 comments


TGen and Dell are pushing the boundaries of computing, and harnessing the power of the cloud to improve healthcare.
On the Case
TGen: Living the Mission

4|9|12   |   2:25   |   3 comments


TGen's CIO puts the organizational mission at the heart of everything the IT staff does.
On the Case
TGen Speeding Up Biomedical Research to Save More Lives

4|5|12   |   1:59   |   8 comments


The Translational Genomics Research Institute is revamping its computing to improve speed, storage, and collaboration – and, most importantly, to save lives.
On the Case
Computing Power Helping to Save Children's Lives

3|28|12   |   2:13   |   3 comments


The Translational Genomics Institute’s partnership with Dell is enabling them to treat kids with neuroblastoma more quickly and save more lives.
Tom Nolle
The Big Reason to Use Office

3|18|14   |   02:24   |   18 comments


Office and personal productivity tools come in a first-class and coach flavor set, but what makes the difference is primarily little things that most users won't encounter. What's the big issue in using something other than Office, and can you get around it?
E2 Editors
SPONSORED: Mobile Security — A Use Case

3|4|14   |   04:27   |   6 comments


New mobile security solutions can accommodate a wide array of needs, including those of a complex university environment.
Tom Nolle
Killing Net Neutrality Might Save You Money

1|16|14   |   2:13   |   11 comments


The DC Court of Appeals voided most of the Neutrality Order, and whatever it might mean for the Internet overall, it might mean better and cheaper Internet VPNs for businesses.
Tom Nolle
The Internet of Everythinguseful

1|10|14   |   2:18   |   19 comments


We really don't want an "Internet of Everything" but even building an Internet of Everythinguseful means setting some ground rules to insure there's value in the process and that costs and risks are minimized.
Tom Nolle
Maturing Google Chrome

12|30|13   |   2.18   |   25 comments


Google's Chrome OS has a lot of potential value and a lot of recent press, but it still needs something to make it more than a thin client. It needs cloud integration, it needs extended APIs via web services, and it needs to suck it up and support a hard drive.
Sara Peters
No More Cookie-Cutter IT

12|23|13   |   03.58   |   21 comments


Creating the right combination of technology, people, and processes for your IT organization is a lot like baking Christmas cookies.
Sara Peters
Smart Wigs Not a Smart Idea

12|5|13   |   3:01   |   46 comments


Sony is seeking a patent for wigs that contain computing devices.
Tom Nolle
Cloud in the Wild

12|4|13   |   02:23   |   15 comments


On a recent African trip I saw examples of the value of the cloud in developing nations, for educational and community development programs. We could build on this, but not only in developing economies, because these same programs are often under-supported even in first-world countries.
E2 Editors
SPONSORED: Is Malware Evading Your IPS?

11|18|13   |   03:16   |   4 comments


Intrusion prevention software is supposed to detect and block malware intrusions, but clever malware authors can evade your IPS in these five main ways.
Sara Peters
Where Have All the Mentors Gone?

9|27|13   |   3:15   |   38 comments


A good professional mentor can change your life for the better... but where do you find one?
Tom Nolle
SDN Wars & You Could Win

9|17|13   |   2:10   |   5 comments


VMware's debate with Cisco on SDN might finally create a fusion between an SDN view that's all about software and another that's all about network equipment. That would be good for every enterprise considering the cloud and SDN.
Ivan Schneider
The Future of the Smart Watch

9|12|13   |   3:19   |   39 comments


Wearing a bulky, oversized watch is good training for the next phase in wristwatches: the Internet-enabled, connected watch. Why the smartphone-tethered connected watch makes sense, plus Ivan demos an entirely new concept for the "smart watch."
Tom Nolle
Cutting Your Cloud Storage Costs

9|4|13   |   2:06   |   3 comments


Cloud storage costs are determined primarily by the rate at which files are changed and the possibility of concurrent access/update. If you can structure your storage use to optimize these factors you can cut costs, perhaps to zero.
Sara Peters
Do CIOs Need an IT Background?

8|29|13   |   2:11   |   23 comments


Most of the CIOs interviewed in the How to Become a CIO series did not start their careers as IT professionals. So is an IT background essential?
Ivan Schneider
The Internet Loves Birthdays

8|27|13   |   3:25   |   69 comments


The Internet has evolved into a machine for drumming up a chorus of "Happy Birthday" messages, from family, friends, friends of friends who you added on Facebook, random people that you circled on G+, and increasingly, automated bots. Enough already.