The 2017 Year in Review of the Department of Justice reveals a Data Analytics Team (the “Team”) for tracking healthcare fraud. The Healthcare Fraud Unit launched the Team in order to provide data mining expertise that efficiently detects healthcare fraud.

Data Mining

The Team will assist prosecutors across the country by using technology to identify “outliers” in the millions of claims submitted to Medicare and Medicaid. Outliers are providers who bill an unusual code or bill a common code more often than normal. Technology also enables the Team to track data about how patients have been diagnosed by other providers, and what subsequent providers report.

Once they have identified an outlier or unusual patient history, investigators can collect documentation from medical files. This can be accomplished through a subpoena, Civil Investigative Demand, or, in more extreme situations, by execution of a search warrant. In addition, investigators can interview office staff and patients in order to evaluate the codes billed by the outlier. These interviews may begin informally, with agents meeting with patients or staff at their homes.

If the documentation and interviews reveal potential fraud, the government can bring a civil lawsuit under the False Claims Act or criminal charges such as Health Care Fraud.

The Compliance Response

Like the government, providers should utilize their compliance programs to look for outliers. Compliance programs can compare provider data to national databases such as the National and Local Coverage Determinations (NCD/LCD) from the Centers for Medicare & Medicaid Services. When anomalies are found, providers can audit medical charts for an objective review of coding decisions. Just as important, chart audits will ensure that documentation is sufficient to justify the chosen code in the event of a challenge by the government.