Confucius[1], a teacher and philosopher known for many sayings, once said “True wisdom is knowing what you don’t know.” In the Fraud, Waste and Abuse community this aphorism should serve as our motto for the daily challenge of getting ahead of the next unknown scheme. There may not be a complete fool proof way to detect 100% of the unknown, but there are best practices and data mining techniques that are more effective than others. Many companies throw out impressive buzz words describing the type of data mining techniques to utilize, and while some of those approaches have merit, they can often overcomplicate the process. So what are some more simplified, yet effective tactics?
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Change in Behavior
What has changed in the data? The “change” could be a number of different things. Some of the most common data elements reviewed to detect a change are the financials such as the dollars billed or dollars paid. The financial review approach, while common, is still a solid way to detect suspect behavior. However, it’s not the only way to identify suspicious activity. What if a provider uses multiple IDs, what if they stop billing under an ID and you didn’t know there was another one? It is important to detect not only significant increases in financials, but financial shifting from one billing practice group to another. Other attributes to consider:
- Changes in patient volume
- Changes in group billing (if applicable)
- Increases in the billing of certain procedures as well as shifts in billing
- Changes in quantity of services per patient
- Changes in units billed per service
Combination of Suspect Behavior Patterns
When reviewing any of the above-mentioned patterns of behavior it is important not to be singularly focused on any one issue. Often times it’s a combination of suspect patterns of behavior which lead you to the strongest case. If you are uncertain which combinations lead to the best results you are not alone. Proven data mining techniques that result in viable investigations this month may not the following months as things are always changing. Continue to modify your approach just as a potential abusive biller continues to modify their approach as well.
If you have questions or are interested in learning more about Healthcare Fraud Shield’s FWA analytics, feel free to email us at SIU@hcfraudshield.com.
[1] Confucius
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