Even though the Center for Medicare and Medicaid Services has imposed new rules and regulations in an effort to combat home health care fraud, there are still going to be individuals who take advantage of loopholes, flaws in the system, and other opportunities to fraudulently acquire money for services not required, necessary, or even provided.
The answer in helping to combat home health care fraud moving forward may lie in artificial intelligence. Researchers at Florida Atlantic University created programs that were intended to detect potential fraudulent activity in Medicare Part B claims. The focus of this research study was to determine whether patterns existed when fraud was evident.
In support of the research study that was recently published, one of its authors, Taghi M. Khoshgoftaar, said, “[These] patterns in the data are hidden.” This means it becomes complicated when human beings are searching for prospective home health care fraud, but artificial intelligence could be a key in helping to detect these costly crimes.
As noted in the abstract of the research report, The effects of varying class distribution on learner behavior for medicare fraud detection with imbalanced big data, conducted by Richard A. Bauder and Taghi M. Khoshgoftaar:
“Healthcare in the United States is a critical aspect of most people’s lives, particularly for the aging demographic. This rising elderly population continues to demand more cost-effective healthcare programs. Medicare is a vital program serving the needs of the elderly in the United States. The growing number of Medicare beneficiaries, along with the enormous volume of money in the healthcare industry, increases the appeal for, and risk of, fraud. In this paper, we focus on the detection of Medicare Part B provider fraud which involves fraudulent activities, such as patient abuse or neglect and billing for services not rendered, perpetrated by providers and other entities who have been excluded from participating in Federal healthcare programs. We discuss Part B data processing and describe a unique process for mapping fraud labels with known fraudulent providers.”
As noted, CMS has developed numerous programs in an effort to combat fraud in the federal government that has taken a more proactive approach and rooting it out, but it (fraud) continues to plague the system. Just two years ago the Office of Inspector General of the United States determined that more than 500 home health agencies and 4,500 physicians may have taken part in suspicious activities related to Medicaid fraud.
Fraud isn’t relegated just to the home health care sector, but is also plagued by hospice care. Any tools that authorities have at their disposal to combat this type of fraud is going to be beneficial, so long as it narrows the net on those who are participating in these illegal activities.