HEALTHCARE PROVIDER DATA FOR ANOMALY DETECTION
Completion Date:
Project Overview
Health care fraud is a type of white collar crime that involves the filing of dishonest health care claims in order to turn a profit. Fraudulent health care schemes come in many forms. Practitioner schemes include: billing by practitioners for care that they never rendered; filing duplicate claims for the same service rendered; altering the dates, description of services, billing for a non-covered service as a covered service; modifying medical records; intentional incorrect reporting of diagnoses or procedures to maximize payment; use of unlicensed staff; accepting or giving kickbacks for member referrals; waiving member co-pays; and prescribing additional or unnecessary treatment.
When a health care fraud is perpetrated, the health care provider passes the costs along to its customers. Because of the pervasiveness of health care fraud, statistics now show that 10 cents of every dollar spent on health care goes toward paying for fraudulent health care claims.
Role:
Problem Statement
Statistics show that 15% of the total Medicare expense is caused due to fraud claims. Insurance companies are the most vulnerable institutions impacted due to these bad practices. The insurance premium is also increasing day by day due to this bad practice.
Fraud costs the nation’s healthcare payers almost $68 billion annually. Between 3 and 10 percent of the country’s $3 trillion in annual spending is related to fraud.
Executive Summary
Data Dictionary
Key Takeaways
Next Steps
1. The data shows that their was an increase in Medicare payment amount by 231% therefore Training healthcare providers and beneficiaries on how to detect fraudulent activities should be implemented and maintained in every healthcare facility.
2. In the 2020 there was an increase in charge amount by 315% therefore beneficiaries should ensure that they carefully review all bills and insurance statements for accuracy and question suspicious expenses.
