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Why Implement Data Mining in the Medicaid Fraud Control Unit?

By David Hart/Monday, October 24, 2016

 

In 2013, the U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) promulgated a rule enabling Medicaid Fraud Control Units (MFCUs) to receive federal funding for their Medicaid fraud data mining efforts provided certain requirements were met.  The rule adds to the toolset that MFCUs have at their disposal for fighting Medicaid fraud and abuse.  But most MFCUs have been reluctant to begin data mining efforts due to concerns over increasing caseloads and expanding federal reporting obligations.

Many MFCUs are now evaluating whether to implement data mining programs. There are several potential benefits to consider for MFCUs contemplating data mining.

Potential benefits:

  • Identify potentially fraudulent providers not previously suspected
  • Identify types of fraud that cannot be systematically detected without data mining
  • Identify additional schemes for a provider already under investigation
  • Prioritize the best cases and reduce wasted time
  • Improve case presentation
  • Ensure a balanced case mix and review of all providers
  • Increase return on investment (ROI)

MFCUs can increase their identification of fraudulent providers, better prioritize cases, and effectively support prosecution efforts by applying best practices, critical success factors, and innovations to data mining efforts. 

Questions to think about when considering data mining:

  • Doesn’t the state Medicaid agency already do this work for the MFCU?
  • Will data mining increase MFCU workload?
  • Will there be evidentiary challenges?
  • Is the cost of data mining prohibitive?
  • Will the application and reporting process be burdensome?

For more than 35 years, Truven Health has used data mining to help clients uncover possible fraud, waste, and abuse, and some of our experience is summarized in a new white paper. To learn more about strategies for implementing successful data mining in a MFCU and guidance to the benefits and questions reviewed in this blog, click here.

David Hart, JD
Vice President, Client Services, State Government

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