Ellen Perlman was a GOVERNING staff writer and technology columnist.E-mail: email@example.com
New York counties, which finance $7 billion a year in Medicaid services, are tapping a new software to catch providers who lie, cheat and steal public dollars with various frauds.
Designed by IBM for the New York State Association of Counties, the software can comb through and analyze medical claims to look for mathematical anomalies. If it "sees" that, say, nearly 5,000 students were sent into speech therapy in one day without evaluation or that one dentist is billing for 1,000 dental procedures a day, the software will report the unusual activity.
It can review providers and recipients and cross-check names and identities to see if false names are being used. The program also can provide peer analysis. It can look at all the cardiologists and compare doctor "X" against doctor "Y" to see if something unusual is going on.
Counties can choose from 19 review categories, such as hospitals or family practices or dentists.
"The county selects what it wishes to profile, where it might have an instinct that there are problems," says Stephen J. Acquario, executive director of the counties association.
New York counties previously did not have the authority to investigate health care provider activity. They could look only at fraud on the part of Medicaid recipients. Now, the counties are pairing with the state to use this new technology to unearth a wider base of fraud.
It could be a goldmine. The U.S. Government Accountability Office has estimated that fraud makes up 10 percent of national health care spending, and Medicaid spending alone is approaching $45 billion nationwide.