Identifying Fraud is Not Always Easy: Analyzing State Medicaid Fraud Control Unit Reports
The U.S. Department of Health and Human Services Office of Inspector General (OIG) recently released a data chart offering fiscal year (FY) 2014 statistical data for the Medicaid Fraud Control Units. For those of you unfamiliar with Medicaid Fraud Control Units (MFCU), the MFC...
Medicaid Managed Care Audits Pay Off…In the Long Run
In May 2014, the Government Accountability Office (GAO) released a report calling for increased oversight of Medicaid managed care spending (the report can be found here). GAO reported that “Most state and federal program integrity officials we interviewed told us that they di...
Improving Healthcare Error Reporting In Healthcare Audits
The purpose of this paper is to offer a technique to more clearly and fully describe healthcare errors detected in audits, which can lead to improved return on investment (ROI) for healthcare audits.
A clear and complete description of all identified errors in a healthcare au...
Healthcare Data Mining for Fraud Detection: Identify and Reduce False Positives to Build Stronger Models
One of the key goals of healthcare data mining is to reduce false positives. In health care fraud data mining, a false positive occurs when your model identifies a provider that is not engaging in fraudulent activity and that has legitimate reasons for having seemingly aberra...
Peeling the Onion: Achieving More Significant Results by Digging Deeper into CMS Payment Data
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued an audit report to the Centers for Medicare & Medicaid Services (CMS) in February 2015 that illustrates how an audit team can achieve more significant results by simply digging ...
Evaluations Have Standards Too: An Introduction to Government Evaluation Standards
A few years ago, one of our team members served as the masters of ceremonies at a training program for individuals interested in government evaluation. He periodically mentioned the Blue Book in the transitions between the various presenters. Later, during a break, numerous pe...
Why Does Medicare Allow Hospitals to Bill for Kwashiorkor?
On March 6, 2015, the U.S. Department of Health and Human Services Office of Inspector General (OIG) released the latest in a series of reports looking at hospitals’ billing and Medicare paying for Kwashiorkor. For those new to Kwashiorkor, Kwashiorkor is a form of severe protein malnutrition tha...
