Posted May 26, 2012 by Team AnalyticpediA in Newscategory

Fighting Fraud for North Carolina: IBM Way

Medicaid Analyticpedia
Medicaid Analyticpedia

North Carolina’s Department of Health and Human Services (DHHS) has conducted an investigation of Medicaid fraud by using IBM predictive-analytics software similar to that of IBM’s Watson supercomputer.North Carolina’s department of health and human services began collaborating with IBM in 2010 to develop analytics to help identify suspicious billing patterns by healthcare providers. To date, North Carolina has identified $191 million in potentially false Medicaid claims by 206 outpatient behavioral health providers in the state.Using the IBM software, the state has identified suspicious claims that include submissions from providers with patterns of billing that don’t fit “the norm”.

For its fraud detection, the state is using two IBM applications: IBM Fraud and Abuse Management System (FAMS) and IBM InfoSphere Identity Insight to analyze claims of nearly 2 million Medicaid patients and 60,000 providers to detect suspicious billing patterns. FAMS mines data to detect patterns of fraud and abuse using modules configured for North Carolina Medicaid.The algorithms and models are used across the health care industry (both public and private payers) as well as cell phone companies, property and casualty insurers. The program can detect billing behaviors that suggest fraudulent activity.

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