Eye on Fraud, Waste, and Abuse

Waste, Fraud, and Abuse in Workers' Compensation: the Recent Californkia Experience

Appropriate documentation, billing and coding in interventional pain practice.

Appropriate documentation, billing and coding in interventional pain practice is a crucial issue with a wide arena of regulatory reforms. There have been reports of billions of dollars in losses in health care fraud. Office of Inspector General reports a massive war on health fraud. Substantial savings from prepayment audits for Part B in 1999, and continued criminal filings by the Department o...

Two models to investigate Medicare fraud within unsupervised databases

We propose two models to identify fraud, waste and abuse in Medicare. These models are used to flag health care providers. The motivation for these models is based on observed cases of fraud. The paper details the use of clustering algorithms, regression analysis, and various descriptive statistics that are components of these models. Some of the challenges in the struggle to reduce fraud in Me...

Graph Analysis for Detecting Fraud, Waste, and Abuse in Healthcare Data

Detection of fraud, waste, and abuse (FWA) is an important yet difficult problem. In this paper, we describe a system to detect suspicious activities in large healthcare claims datasets. Each healthcare dataset is viewed as a heterogeneous network of patients, doctors, pharmacies, and other entities. These networks can be large, with millions of patients, hundreds of thousands of doctors, and t...

Making sense of physician regulatory risk in the post-health reform era.

a variety of faCtorS iS CoaleSCing on the state and national levels that have increased the risks to physicians and other health care providers relating to fraud, waste and abuse. Though most enforcement resources are being directed, rightly, at true “bad guys” (providers intentionally defrauding the governmental and private health care payors), the complexity of providing health care in the po...