Over the years, the Department of Health and Human Services Office of Inspector General and the Centers for Medicare & Medicaid Services contractors have utilized data analytics to root out fraud, waste and abuse across the health care industry. In fact, in 2013 the General Accountability Office (GAO), Council of the Inspectors General on Integrity and Efficiency (all the federal Offices of Inspector General), and the Recovery Accountability and Transparency Board convened a forum to discuss the ways in which oversight and law enforcement agencies use data analytics to help detect and prevent instances of fraud, waste and abuse. They also collaborated to identify the most significant challenges relating to using data analytics for these purposes and how the government can address such challenges.
After the forum, the GAO issued a report detailing what was discussed and determined when it comes to sharing data, knowledge and analytic tools to assist government agencies in their efforts to combat fraud, waste and abuse. The report also summarized key themes that emerged from the forum, specifically the challenges and opportunities in (1) accessing and using data and (2) sharing data. According to the report, the forum participants noted that:
- Consolidation of data and analytical operations can enhance the return on investment.
- Using predictive analytics to identify fraudulent claims before payment is preferable.
- Garnering agency support in using data analytics is key to success.
- There is a lack of incentives to design information technology systems to identify fraud, waste and abuse.
- There is a lack of incentives by program offices to share data with the oversight community.
- Available data may be overwhelming for oversight and law enforcement.
- There can be various legal implications of owning and maintaining data.
- Measuring successes of an analytical program is difficult.
- It is critical to have a knowledgeable and skilled staff to do the analytical work.
- Varying data standards across the government makes it difficult to share data.
In addition, forum participants identified next steps to address these challenges and capitalize on opportunities that they also discussed.
Given these results, the three organizations that sponsored the forum agreed to compile a consolidated directory of data sources to increase awareness of where to find the right kind of data for detecting fraud, waste and abuse. They also decided to compile a library of available open-source data analytics, modules and tools, develop an ongoing community of practice focused on data-sharing and examine the existing statutory framework to determine what changes, if any, are necessary to eliminate data analytics barriers in order for enforcement agencies to carry out their missions.
Since the forum and release of the GAO report, the trend of using data systems and technology in support of oversight and law enforcement has continued at an increasing rate. The findings from both platforms point to the fact that data analytics is widely seen as a useful tool to identify and prevent fraud, waste and abuse. As technological capabilities continue to improve, law enforcement agencies will likely see a parallel improvement in the methods in which data analytics can be used to combat non-compliance in the industry.