if you build it, they may come — anti-fraud AI software


Sherlock Holmes

TRICARE’s Program Integrity Office Battles Fraud

by Tricare: BlackAnthem.com Military News 29 Oct. 2007

“… The Government Accountability Office says that 10 percent of all health care expenditures are fraudulent. TRICARE‘s [see] first line of defense against health care fraud is its Program Integrity Office, and the proof is in the office’s recently-released annual operational report.

“The Program Integrity Office is responsible for all anti-fraud activity worldwide for the entire Defense Health Program, including the purchased care and direct care settings of the Military Health System.

“‘Our mission is to ensure that appropriate anti-fraud controls are in place because it’s a major part of ensuring quality health care for our military families,’ says Rose Sabo, Director of the TRICARE Program Integrity Office. ‘It’s also a major part of ensuring the appropriate expenditure of taxpayer dollars.’

“The Program Integrity Office’ investigations have helped DoD recover huge sums but Sabo says that’s not their only focus.

“‘Patient harm cases are the worst,’ Sabo said. ‘We give those as high a priority as cases that are high dollar.’

“To get TRICARE’s contractors highly involved in the effort to avoid medical payment scams, Sabo launched Operation TRICARE Fraud Watch in 1999. The dental contractor, the pharmacy contractor and the managed care contractors use what’s called link analysis artificial intelligence [see] [see] software to identify odd billing patterns and cost aberrations. The Program Integrity team also has access to Medicare‘s database and receives notices from the Department of Justice when whistleblowers make allegations against any health care program. By using a centralized purchase care data warehouse, they can then look at a provider’s pattern of billing to determine whether allegations are supported.” . . . (full article)

Article Source: BlackAnthem.com Military News

Photo Source: Student Britannica






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