Posted and filed under Fraud, FWA, Healthcare.

Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

This past week I attended a CMS “listening session” hosted by the Center for Program Integrity (CPI).  The session I attended was on the use of artificial intelligence in regards combating fraud, waste and abuse. In looking around the room, and spotting the name and company badges, I think I was the only person that was not from an IT services company.

For those that do not know, CPI is the division within CMS that is responsible for fraud, waste and abuse initiatives and services. They oversee such things as the Unified Case Management (UCM), and the project that I was privileged to have been part of when I first retired from the OIG. They are also responsible for the fraud prevention system and a host of other very important tools.  Overall, every person who spoke was impressive in their backgrounds, company platform and the “shameless plug” for their products. It was enjoyable to hear each person stand up and say, “I’ll give a shameless plug to…” and then name their software platform.

What I found a bit surprising was that every tool discussed had some potentially unbelievable artificial intelligence functions, but no one brought up leveraging a human element along with the tool.  I understand that using artificial intelligence is an important part of progressive fraud identification; with 1.2 billion claims processed by Medicare, it must use data and artificial intelligence to just manage the sheer volume of information. However, even with the aggressive data modeling that the healthcare fraud strike force model employs, it still relies on experienced fraud investigators (OIG shameless plug here) to work through what is alleged and put a human reasoning into the mix.

CPI had some very aggressive ideas on what they were looking for from industry in the future.  It was refreshing to see that this is the shift of the division, as in years past, I’m not sure that was always the position. The OIG and CPI enjoy a great relationship, due greatly in part to the Director of CPI’s background, and his understanding of the moving parts.

If you happen to have been one of many who likely provided insights at the listening sessions, have pitched CPI on your tool, and/or responded to one of the two Requests For Information, I urge you not to miss sight on the fact that as good as artificial intelligence is, there will always be fraud, waste and abuse schemes that are uncovered by none other than a well-trained healthcare fraud investigator.

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.