Fighting Healthcare fraud and over-prescriptions with predictive analytics

By Claire Thayer, October 31, 2017

Earlier this summer, the U.S. Department of Justice announced the largest ever health care fraud enforcement action, involving over 412 individuals across 41 federal districts, including 115 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes. Of those charged, over 120 defendants, including doctors, were charged for their roles in prescribing and distributing opioids and other dangerous narcotics. Adoption of prescription drug monitoring programs is one way to hold health care providers accountable for overprescribing practices. Use of sophisticated claims analytic tools can help detect suspicious practice patterns as well. A health plan in the Midwest recently uncovered the case of an overprescribing neurologist using peer-to-peer analysis for comparison of practice patterns.

This recent edition of the MCOL Infographic, co-sponsored by LexisNexis, provides highlights from this case study: