The Growing Role of Data Analytics in Healthcare Enforcement

The US Division of Justice (DOJ) and US Division of Well being and Human Providers, Workplace of Inspector Basic (HHS-OIG) are more and more counting on refined information analytics instruments to determine and examine fraud schemes, notably in the healthcare sector. DOJ’s announcement of 4 new False Claims Act settlements and instances involving related fraudulent billing schemes additional demonstrates the effectiveness and significance of DOJ and HHS-OIG’s information analytics applications. Healthcare corporations ought to take steps to organize for these data-driven enforcement actions and incorporate information analytics into their very own compliance and audit applications.

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The US Division of Justice (DOJ), US Division of Well being and Human Providers, Workplace of Inspector Basic (HHS-OIG), and different federal companies have lengthy mentioned utilizing information analytics to determine and examine fraud and different legal conduct. Data analytics is the method of inspecting information units to attract conclusions and determine patterns in regards to the data they include. Aided by developments in know-how and extra sturdy and useable information units, federal companies are lastly utilizing this game-changing investigative software to successfully and effectively pursue legal and civil enforcement actions, as defined in this Bloomberg Law article. DOJ’s most up-to-date healthcare enforcement issues additional display this pattern, notably in the healthcare sector.

On October 14, 2021, DOJ announced the latest four enforcement actions in an ongoing nationwide investigation into an alleged improper billing scheme involving P-Stim electro-acupuncture units. Federal healthcare applications don’t reimburse for P-Stim units, however the events promoted them as billable to Medicare and different federal healthcare applications, inflicting suppliers to submit fraudulent claims. This ongoing nationwide initiative has produced greater than 15 False Claims Act (FCA) settlements nationwide value roughly $15 million.

DOJ introduced that the enforcement actions stemmed straight from its use of information analytics. The company emphasised that the Japanese District of Pennsylvania (the district in which the enforcement actions had been filed) helps to guide the “national Department of Justice effort to apply analytics to healthcare claims data to identify providers who have fraudulently billed federal healthcare programs.”

In line with these most up-to-date enforcement actions, DOJ and HHS-OIG (amongst others) more and more are emphasizing and counting on information analytics to determine and fight fraud and abuse in the healthcare context. HHS-OIG’s information scientists and statisticians use a spread of refined information analytics instruments, together with predictive and geospatial analytics and synthetic intelligence, to look at huge quantities of healthcare, legislation enforcement and operational information. This enables HHS-OIG to shortly determine tendencies, outliers and potential investigative targets. As soon as HHS-OIG or DOJ identifies new tendencies and kinds of fraud schemes, their information analytics instruments permit them to quickly determine and goal related situations of fraud all through the nation—which seems to be precisely what occurred in the latest P-Stim system FCA instances.

DOJ and HHS-OIG’s elevated use of information analytics has already led to a big rise in the quantity of federal FCA instances initiated straight by DOJ versus through qui tam whistleblower complaints. DOJ initiated 100 extra FCA instances in 2020 than it did in 2019, ensuing in essentially the most non-qui-tam FCA instances filed in virtually 30 years. The quantity of data-driven FCA fraud investigations will seemingly proceed to extend, notably as the federal government continues to research potential fraud related to the CARES Act, the Supplier Aid Fund and the COVID-19 pandemic.

All healthcare corporations and suppliers ought to be conscious of DOJ and HHS-OIG’s elevated reliance on information analytics and may take steps to organize for any potential data-driven enforcement actions. Corporations ought to incorporate refined information analytics into their audit and compliance applications to reduce enforcement threat. Simply as the federal government can use information analytics to quickly determine and examine fraud and abuse, corporations can likewise use it to determine dangers early and keep away from being ensnared in pricey authorities investigations and prosecutions. Corporations ought to proceed to observe high-risk areas, consider whether or not all information regarding these threat areas are literally being collected, and put in place programs to make sure that the info collected is successfully monitored and analyzed to determine any potential errors and/or misconduct. To the extent an organization finds itself topic to a authorities enforcement motion, protection counsel ought to conduct their very own information evaluation to organize an efficient protection technique. Data analytics may be instrumental in serving to healthcare corporations reply to FCA claims or different enforcement actions.

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