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DoJ uses big data to crack Medicare fraud schemes

13/01/2015 by Sharon Shahzad


US authorities have saved billions of dollars by mining big data to identify and prosecute healthcare fraud, learning from the playbook corporations are using to disrupt their industries and expand their businesses.

The US Department of Justice, Federal Bureau of Investigation and Department of Health and Human Services’ office of inspector general have been scouring billing records to identify frauds that are estimated to bleed Medicare, the taxpayer-funded safety net for 54m elderly and disabled Americans, of more than $60bn annually.

Since launching a co-ordinated strike force in 2007 in Miami, the US government has seen the effort pay off. It said it recovered a record $4.3bn in 2013 in fines and restitution and $19.2bn over the past five years. For every dollar spent prosecuting healthcare fraud, the US says it has collected $8.

The initiative — to comb real-time data to catch and then stop fraudsters in the act — is still a new concept within the DoJ’s fraud section, which is also responsible for prosecuting foreign bribery, securities fraud and bank fraud.

“The idea of using real-time data to generate fraud cases is unique,” said Leslie Caldwell, the chief of the criminal division at the DoJ.

“We’ve asked our fraud prosecutors to see whether there are similar areas where there are other databases,” Ms Caldwell said. “We’ve asked people to think creatively in terms of information sources that could show us some hotspots in other areas” beyond healthcare, she said. “If there are, we’re going to look at them.”

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