Data analytics is not a new concept within the health care industry. However, as data analytics tools become more accessible, government interest in using data analytics to detect health care fraud continues to increase. Government investigators also have been vocal in informing the health care industry that this powerful tool will continue to be used.

For example, the House Ways and Means Subcommittee on Oversight recently held a hearing on the government’s use of data analytics to combat health care fraud. Testifying witnesses included a representative from the Centers for Medicare and Medicaid Services (CMS), who discussed the use of data analytics to identify excluded individuals. A representative from the U.S. Department of Health and Human Services Office of Inspector General (OIG) discussed the use of data analytics by the agency and the Medicare Fraud Strike Force for prospective and investigative purposes.

Additionally, the New York Office of the Medicaid Inspector General (OMIG) recently released its 2015-2016 Work Plan, which includes performing data analytics related to controlled substances to identify prescribers with exceptional prescribing patterns. The review will include whether these prescriptions were medically necessary.

Two significant databases released by CMS – Open Payments and Medicare Provider Utilization and Payment Data – are examples of data sources publicly available for sophisticated data analytics.

Health care entities should consider integrating data analytics into their compliance program auditing and monitoring activities. Key areas of focus will depend based on the type of health care entity, but may include data breach prevention, prescription drug diversion and abuse, fraudulent claims, and kickbacks.

Posted by Cooley

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