Medical claims 'mined' to find fraud - USATODAY.com: "Medicare investigators in Los Angeles, using sophisticated computer technology to sift through claims data, saw an unusual pattern: A single patient had apparently undergone a diagnostic rectal-probe procedure 118 times in a year — at 21 medical facilities.
'It's unlikely that could have occurred,' says Kim Brandt, director of program integrity at the Centers for Medicare and Medicaid Services. 'This person would not have been able to sit on a plane.'
Borrowing techniques from financial and credit services, Medicare and private health insurers are increasingly 'mining' claims data for suspicious patterns, comparing practitioners with their peers and larger databases of claims.
STORY: Computer programs help flag insurance fraud before payment
Medicare investigators found similar cases across a group of diagnostic testing companies, which used improperly obtained Medicare patient identification numbers to bill for the exams, which were likely never performed. Problems were found with other types of tests as well. As a result, 83 diagnostic centers this year lost their billing privileges, and $163 million in payments were denied.
Without the computer program, the fraud might have gone undetected.
'I call it spider-webbing: Find one common denominator (and follow the thread),' says Brandt."
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