Despite an expensive and high profile zero-tolerance crackdown, it’s believed more than $210 billion was lost in the US through healthcare fraud in 2014. It’s a staggering figure based on a 3-7% estimated fraud rate.
Could graphs be part of the answer? Let’s take a look at how graph visualization could be a valuable tool for detecting healthcare fraud, focusing on the Medicare Program.
The national Medicare program covers 54 million Americans and accounts for 14% of the annual federal budget, costing $492bn in 2013.
With any program at this scale, the scope for fraudsters is vast. The number and complexity of transactions makes detecting fraud seem like finding a needle in a haystack. The problems are compounded by the desperate state of federal and state-level computer systems. Records are spread across multiple data silos, held by different agencies with no simple way to cross-reference.
But what if Medicare data were to be viewed as a graph?
As with all fraud detection, the key is to understand connections: between patients, procedures, practitioners and clinics.
Using this model, we can identify ‘normal’ patterns:
We can therefore rapidly identify cases of probable healthcare fraud. Let’s take a look at some examples.
One of the most common, and costly, types of Medicare fraud is when practitioners bill for services they haven’t provided. Often this is done using social security numbers that have been stolen from seniors, either directly or using social engineering tactics.
Just last week, the FBI shut down one Medicare fraud ring operating in Florida using stolen social security and provider information to steal $28.3 million.
As millions of claims are submitted each month, Medicare authorities cannot check each bill with the patients concerned. In any case, many patients do not fully know or remember which services they received, and certainly don’t understand the obscure procedure codes used.
Rather than relying on tip-offs from members of the public, analysts could use a tool like KeyLines to find potential cases of fraud.
These are just a few simplified examples of how graph visualization can be used to detect possible cases Medicare fraud. By benchmarking ‘normal’ behavior, outliers and anomalies become rapidly visible when visualizing our data.
Download our white paper ‘Detecting fraud with KeyLines’ to see how KeyLines has been used to visualize fraud data, or get in touch to try it for yourself.