Auditors Using Sophisticated Data Mining Techniques to Identify Fraud

Auditing entities are utilizing more sophisticated electronic data mining methods than ever before. Today’s sophisticated data mining techniques enable auditors to identify greater cost recoveries, making auditing activities both more efficient and more effective.

Auditors utilize statistical data mining testing to determine whether a provider’s billing practices are statistically different from their peers’. If data patterns from a provider’s utilization rates are significantly different from that of their peers’, auditors are able to identify situations where a provider’s practices may be improper. By mining data on a regular basis, healthcare auditors isolate potential fraud and abuse.

Comparative Billing Reports (CBRs), a tool used by CMS to educate providers about their individual billing practices, detail complex statistical analysis in the form of charts and graphs and show how a practices’ utilization rates compare to those of their peer group. Safeguard Services, LLC, a company contracted by CMS, produces and sends out CBRs to certain provider types. CBRs compare both state and national standards and may help a provider detect possible billing and coding problems for their practice.

CBRs alert healthcare providers of the possibility that their services are being improperly billed to Medicare and help providers ensure that their practices comply with Medicare billing rules. Medicare auditors use data mining analyses to recognize potential “outliers,” whose practices deviate from the mean in a statistically significant way. As a result of the sophisticated statistical scrutiny used in CBRs, it is important for healthcare providers to understand how their coding and billing practices compare to coding and billing practices of their peers.

Although identifying an “outlier” does not guarantee that a provider’s practices are improper, auditors are able to recognize potential issues. It is essential that providers conduct internal reviews and risk assessments, and understand the statistical analysis auditors employ in a CBR. Benchmarking charts allow providers to compare billing and utilizing practices to those of their peers.

If your provider type has been identified to receive a CBR, or if you are already a recipient of a CBR, please contact an experienced healthcare attorney at Wachler & Associates at 248-544-0888 to discuss evaluating your CBR analysis and to create an appropriate compliance plan that will reduce audit risks.