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Medicaid fraud, computer analytics and false allegations

Medicaid fraud is, essentially, the illegal practice of seeking payment from the Medicaid system. The Obama Administration aimed to reduce Medicaid fraud throughout the country. Although a noble goal, there are concerns that the methods used could result in false allegations of fraudulent practices by medical professionals.

One concern involves the use of computer analytics in an attempt to ferret out physicians that are allegedly attempting to undermine the system.

How does the program work?

The program in question was designed by the Centers for Medicare and Medicaid Services (CMS). It uses predictive analytics to search for medical professionals that may be committing fraud.

A recent article in The Fiscal Times discussed this system, noting that it manipulates four different forms of predictive analytics to predict who may be guilty of fraudulent practices. The four types in use are:

  • Rules-based. This model focuses on an analysis of numbers. If the program finds numbers that are deemed to be either stolen or fraudulent, an alert is issued.
  • Anomaly. This form is designed to review the types of billing made by a physician. If the program determines that too many requests for payments were made, the physician, hospital or medical group will be flagged for further review.
  • Predictive. Predictive analytics compares current practices to past fraudulent practices. An alert results when too many similarities are present.
  • Social networking. This model proves that networking is not always a good thing. With this model, physicians and medical practitioners that have ties to others in their field that have been found guilty of fraudulent practices are flagged for review.

This system can result in allegations of fraudulent practices in a wide range of instances. For example, simply being located in a geographic area that has a history of fraud can result in an investigation.

What should I do if I am accused of Medicaid fraud?

Allegations of fraudulent practices can be very damaging to a physician's career. As a result, it is important for those who are facing charges to take the allegations seriously. Contact an experienced lawyer to help better ensure your rights are protected.

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