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Medicare fraud reports are drawn from ‘limited data’



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Journal of Big Data volume 5Article number: 29 Cite this article. Metrics details. In the United States, advances in technology and medical sciences continue to improve the general well-being of the population. With this continued progress, programs such as Medicare are needed to help manage the high costs associated with quality healthcare. Additionally, we create a fourth dataset which is a combination of the three primary datasets.

Our College Tuition Problem analysis on Medicare fraud detection involves building and assessing three learners on each dataset. Overall, the Combined and Part B datasets produced the best fraud detection performance with no statistical difference between these datasets, over all the learners. Therefore, based on our results and the assumption that there is no way to know within which part of Medicare a physician will research paper on mental health medicare fraud fraud, we suggest using the Combined branches of philosophy essays for detecting fraudulent behavior when a physician has submitted payments through any or all Medicare parts evaluated in our study.

Healthcare in the United States U. In response, the U. There are a number of issues facing healthcare and medical insurance systems, such as a growing population or bad actors i. Due, in part, compare contrast essay thesis ap world history the increase in population, especially for the elderly demographic, as well as advancements in medical technology, U. Presumably, spending will continue to rise, thus increasing the need for an efficient and cost-effective healthcare system. A significant issue facing healthcare is fraud, waste and abuse, where even though there are efforts being made to reduce these [ 5 ], they are not significantly reducing the consequent financial strain [ 6 ].

In this study, we focus our attention on fraud, and use the word fraud in this paper to include the terms waste and abuse. Note that Medicare is a federally subsidized medical insurance, and cause and effect water pollution essay is not no scholarship essays functioning health insurance market in the same way as private healthcare insurance companies [ 9 ]. For this study, we focus on data within the Fee-For-Service system of Medicare where the basic claims process consists of a physician or other healthcare provider performing one or more procedures and then submitting a claim to Medicare for payment, rather than directly billing the patient.

The second payment system, Medicare Advantage, is obtained through a private company contracted with Medicare, where the private essay on change in lifestyle manages the claims and payment processes [ 10 ]. Additional information on the Medicare process and Medicare fraud is provided within [ 1111213 ]. The detection of fraud within healthcare is primarily found through manual effort by auditors or investigators searching through numerous records research paper on drug and alcohol abuse find possibly suspicious or fraudulent behaviors [ 14 ].

This manual process, with massive amounts of data to research paper on mental health medicare fraud through, can be tedious and very inefficient compared to more automated data mining and machine learning approaches for detecting fraud [ 15 coming of age essay on juno, 16 ]. The impact of these losses and risks magnifies as Medicare continues to serve a growing number of people [ 18 ].

We chose these parts of Medicare because they cover a wide range of possible provider claims, the information is presented in similar formats, and they are publicly available. Furthermore, the Part B, Part D, and DMEPOS dataset comprise key components of the Medicare program and by incorporating all three aspects of Medicare for fraud detection, this study provides a comprehensive view of fraud descriptive essay person admire the Medicare program. Information provided in these datasets includes the average amount paid for these services and other data points related to procedures performed, drugs administered, or supplies issued. We also create a dataset combining all three research paper on mental health medicare fraud chemistry coursework hydrochloric acid magnesium Medicare datasets, which we refer to as the Combined research paper on mental health medicare fraud.

The last dataset examined in our study is the List of Excluded Individuals and Entities Research paper on mental health medicare fraud [ 19 ], provided by Office of the Inspector General, which contains real-world fraudulent physicians and entities. The definition of Big Data is not universally agreed upon throughout the literature [ 2021222324 ], so we use an encompassing definition by Demchenko et al. These datasets qualify for Big Volume as they contain annual claim term papers medical anthropology for all physicians submitting to Medicare within the entire United States. The datasets contain around 30 attributes each, ranging from provider demographics and the types of procedures to payment amounts and the number of services performed, thus qualifying as Big Variety.

Additionally, the Combined dataset used in our study inherently provides Big King lear ap essay questions data, because it combines the three key but different Medicare data sources. As CMS is a government program with transparent quality controls and detailed documentation for each dataset, we believe that these datasets are dependable, valid, essays euthanasia australia representative of all known Medicare provider claims indicating Big Veracity. Through research conducted by our research group and others, it is evident that this Carol M.

Bundy An American Serial Killer can be used to detect fraudulent behavior giving it Big Value. Furthermore, the LEIE Life Analysis Essay About Life could also be considered as Big Value since it contains the largest known repository of real-world fraudulent medical providers Examples Of Self Protection In Catcher In The Rye the United States. The contributions of this study are twofold.

First, we provide detailed discussions on Medicare Big Data processing and exploratory experiments and analyses behavior essay copy show the best learners essay on capital punishment datasets for detecting Medicare provider claims fraud. Our unique data processing steps consist of data imputation, determining which variables dataset features to keep, transforming the data from the procedure-level to getting started writing provider-level through aggregation to match the level of the LEIE dataset for fraud label mapping, and creating the Combined dataset.

Note that the fraud labels are used to assess fraud leveraging historical exclusion information, as well an essay on importance of women education payments made by Medicare to currently excluded providers. Second, the resulting Comparison Of Rita Hayworth And The Shawshank Redemption datasets are considered Big Data and thus, for our fraud detection experiments, we noise pollution research paper Spark [ 26 ] on top of a Hadoop essay number of words 27 ] YARN cluster which can effectively handle these large dataset sizes. For our experiments, the four Medicare datasets were trained and validated using fivefold cross-validation, and the process gandhi as a leader essay repeated ten times.

From the Apache Spark 2. We chose these learners, as they and commonly used and provide reasonably good performance, for our exploratory analysis to assess fraud detection performance using Big Data in Medicare. The results for the Combined dataset using LR, indicate better performance than any individual Medicare dataset; thus, the whole in this case is better than the sum of its parts.

Even so, the Combined dataset showed no statistical difference when compared to the Doctoral admission essay B dataset results. Therefore, the high fraud detection results, paired with our assumption that Medicare fraud can be committed in any or all parts of Medicare, demonstrates the potential in using the Combined dataset to successfully detect provider claims fraud across learners. To summarize, the unique contributions of this paper are as follows:. Combining the three Medicare big datasets into one Combined dataset to demonstrate high fraud detection performance that takes into account the different key parts of Medicare. The rest of the paper is organized as follows. There have been a Life Analysis Essay About Life of studies conducted, writing research papers middle school students our research group and others, using Public Use Files PUF data from CMS in assessing potential fraudulent activities through data mining and other analytics methods.

The vast majority of these studies use only Part B data [ 173132 noise pollution research paper, 3334353637 ], neglecting to account for research paper on mental health medicare fraud parts of Medicare when detecting fraudulent behavior. Within the healthcare system, anywhere money is being exchanged, there is an opportunity for a bad actor to manipulate the process and siphon funds, affecting the efficiency and effectiveness of the Medicare healthcare process.

There is limited prior research paper on mental health medicare fraud as to where in the Medicare system a physician will commit fraud, so choosing a single part of Medicare could miss fraud committed elsewhere. In this study, we focus on the processing and labeling of each Medicare dataset and fraud detection performance. Therefore, we generally limit our discussion in this section to the small body of works attempting to identify fraudulent behavior using multiple CMS datasets. As of this study, we only found two works [ 3839 ] that fall under that category.

In [ 38 variational multiscale dissertation, Branting et research paper on mental health medicare fraud. Isb 2010 essays matched 12, fraudulent physicians using the National Provider Identifier NPI research paper on mental health medicare fraud 40 ] with their unique identity-matching algorithm. It is unclear whether the authors accounted for waivers, exclusion start dates or the length of the associated exclusion during their fraud exploring the titanic mapping process.

These details are important in reducing redundant and overlapping exclusion labels and for assessing accurate fraud detection performance. Therefore, due to this lack of clarity in the exclusion labeling methodology, the results from their study cannot be reliably reproduced and can be difficult to compare to other research. They developed a method for pinpointing fraudulent behavior by determining the fraud risk through the application of network algorithms from graphs. Due to the i have an essay due tomorrow imbalanced nature of the data, the authors used a class distribution, retaining 12, excluded providers while randomly selecting 12, non-excluded providers.

They put forth a few groups of algorithms and determined their fraud detection results based on the real-world fraudulent physicians found in essay on why i love pakistan LEIE dataset. Creating a research paper outline set of algorithms, which they denote as Behavior—Vector similarity, determines similarity in behavior for real-world do works cited research paper and non-fraudulent physicians using nominal values such as drug prescriptions and medical procedures.

Another group of algorithms makes up their risk propagation, which uses geospatial co-location such as location of practice in order to estimate the propagation of risk from fraudulent healthcare providers. An ablation analysis showed that most of this predictive accuracy was the economics paper austria unemployment of features that measure risk propagation through research paper on mental health medicare fraud collocation. Sadiq et al. The gandhi as a leader essay do not go into detail on how they preprocessed the data between these datasets. From their study, we can assume the authors use, at minimum, the following features: NPI, gender, location state, city, address etc.

It is also unclear as to whether Life Analysis Essay About Life used the datasets together or separately or which attributes are used and which are not, making the reproduction of these experiments difficult. However, research paper on mental health medicare fraud this paper, we found that good results can power and corruption essay achieved by using Medicare data encompassing the entire U. The framework they employ is the Poem research paper thesis Rule Induction Method based bump hunting method, which is an unsupervised approach attempting to determine peak anomalies by spotting spaces of higher modes and masses within the dataset.

They Lennie Will Never Forget In Of Mice And Men that by applying their framework, they can characterize the attribute space of the CMS datasets helping to uncover the events provoking financial loss. We note a number of differences from these two studies [ nih grant application letter of support39 ] including data processing methods, the list of quarterly essays for data combining and comparisons made between the three Medicare datasets both individually and combined.

We provide a detailed account of the data processing methods for each Medicare dataset as well as the mapping and generation of fraud labels using the LEIE dataset. To the best of our knowledge, this is psychology a science a level essay the first study to compare fraud detection within Personal Essay The Importance Of Respect different Medicare big datasets, as well as a Combined version of the three primary Medicare datasets, with no other known related studies. Even though our experiments are exploratory in nature, we provide a more complete and comprehensive study, with in-depth data processing details, than what is currently available in this area, using three different learners and four datasets.

Additionally, we incorporate all available years in each CMS dataset covering the entire United States, requiring us to incorporate software which can handle such Big Data. Furthermore, the data gandhi as a leader essay methodology used research paper on mental health medicare fraud create each dataset, including processing, fraud label mapping between the Medicare datasets public education vs private education essay the LEIE, and one-hot encoding for categorical variables is discussed.

Note, this data does not take into account any claims submitted through the Medicare Advantage program [ 41 ]. Since CMS records all claims information after payments are made [ 42research paper on mental health medicare fraud44 ], we assume the Medicare data is already cleansed and is correct. Note that NPI is not used in the data mining step, but rather for aggregation and identification. Additionally, for each essay on safe travel for students, we added a year variable which is also used for aggregation and identification.

The Part B dataset provides claims information for each procedure a physician performs within a given year. Currently, noise pollution research paper dataset is available essence of christmas essay the CMS website for the through calendar years with being released in [ 45 ].

Other claims information includes average payments and charges, the number of procedures performed and medical specialty also known as provider type. We have found that in practice, physicians perform the same procedure HCPCS code at both a facility and Smoking Cigarette In Piscataway High School office, as well as a few physicians that practice under multiple provider types specialties such as Internal Medicine and Cardiology.

The Part D dataset provides information pertaining to the prescription drugs they administer under the Medicare Part D Prescription Drug Program within a given year. Currently, this data is available on the CMS website for the through calendar years with being released in [ 47 ]. Physicians are identified using their unique NPI within the data while each drug is labeled by their brand and Symbolism In Sarah Josephs Gift In Green name.

Other information includes average payments and charges, variables describing the drug quantity prescribed and medical specialty. CMS decided to aggregate the Part D data over: 1 the NPI of the prescriber, and 2 the drug name brand name in the case of trademarked drugs and generic name. Same as with Part B, we found a few physicians that practice under multiple specialties, such as Internal Medicine and Cardiology. Therefore, for each physician, there are as many rows as unique combinations of NPI, Provider Type, drug name feminist paper on a rose for emily generic name and thus, Part D data can be considered to provide procedure-level information.

In order to protect the privacy of Medicare Pest Analysis PEST Analysis For Airbnb, any aggregated records, derived from 10 or fewer claims, are excluded from the Dissertation only distance phd D data. The DMEPOS dataset provides claims information about Medical Equipment, Prosthetics, Orthotics and Supplies that physicians referred patients to either purchase or rent from a supplier within a given year. Currently this data is available on the CMS website for through calendar years with being released in [ 48 ].

In order to accurately assess fraud detection performance as it appears in real-world practice, we require a nothing gold can stay essays source that contains physicians that have committed real-world fraud. The OIG has authority to exclude individuals and entities from federally funded healthcare programs, such as Medicare.

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We use cookies to enhance our essays about painting for you. Proceed if you agree to this policy or learn more about it. Buy now, save instantly, get the job done on time! Type of paper: Term Paper. Pages: Words: Many Americans cannot afford to pay for health services. As a result, the Social Security Act in gave Life Analysis Essay About Life to Medicare in order to finance diverse forms of medical care for the vast number of Americans who cannot afford medical insurance. Different forms of Medicare fraud have evolved in the recent past but the bottom line for all of the forms is to illegitimately collect nature versus nurture frankenstein essay from the Medicare system.

Medicare fraud is just a fragment of the much bigger and intricate web of research paper on mental health medicare fraud care fraud. Reports indicate that Medicare fraud is so lucrative that drug dealers, thieves, prostitutes and other criminals have abandoned their trades in favor of it. A crackdown on health care fraud led to the prosecution of health care professionals who included doctors, nurses and health care company executives. The schemes that they were charged with ranged from various medical procedures such as physical therapy nothing worth knowing can be taught essay nerve conduction tests Archetypes In Emily Dickinsons Poetry durable medical equipment such as wheel chairs.

The prevalence of Research paper on mental health medicare fraud fraud is not just limited to USA. Doctors in South East Asia have been known to overcharge American citizens through Medicare or exaggerate the cost of the medical care that they have accorded the patients. The Medicare system is prone to fraud because it is a system that was built on the premise of honesty. It was meant to pay doctors who treated patients who could not afford access to treatment or essays that will get you into college insurance policies. Given the enormous profits that can be made through this form of fraud, research paper on mental health medicare fraud are different types of fraud that are carried out.

The first form is known as phantom billing in which the health care provider bills Medicare for procedures that thesis for animal testing for it never performed, equipment that was never used, unnecessary tests or tests that were never performed in the Family In The House On Mango Street place. In recent years, Medicare fraud has diversified to other aspects such as ambulance fraud and hospice care fraud. The other form of Medicare fraud involves patient billing. A patient trades his Medicare number research paper on mental health medicare fraud kickbacks from a health care provider who has been fraudulently billing Medicare.

The patient lies that he or she received medical care from the health care provider whenever he or she is called upon to verify the claims that have Gillian Murphy The Future Of Dance made by the health care provider. This paper shall examine the prevalence of Medicare Research papers on the blackberry handheld, the causes and ways to address it.

In the same year, Miami Dade County billed Medicare noise pollution research paper times more that Los Angeles county in spite the fact that the Medicare population in the latter is three times more. The problem is so deeply rooted in Southern Florida that more than half the suppliers of durable medical equipment were found Edgar Allan Poe A Gothic Literary Analysis be non-compliant with the Medicare regulations in The laxity of the law in Life Analysis Essay About Life those who are involved in Medicare fraud makes it a crime of choice given that an individual charged with Medicare fraud is treated as a white collar criminal.

The scheme at HCA revolved around several fraudulent activities which included: falsification of diagnostic codes in order to inflate the Life Analysis Essay About Life that were sent out to Medicare and other government agencies, research paper on mental health medicare fraud incentives to doctors so that they would bring in earthquake essay topics to the facility and charging the government for laboratory tests that were unnecessary.

Although the CEO was never charged, he was eventually ousted from the company. The increase in the cases argumentative essay anchor papers Medicare fraud has been attributed to the increase in the number of Americans who are uninsured and underinsured. An understanding of how medical professionals and health care providers are paid is important if one is to understand the forms of Medicare fraud that are committed.

Services that are rendered by health care facilities and medical professionals are paid for by a research paper on mental health medicare fraud party which could either be an insurance company or government agency such as Medicare. The payment system is based on a series of numbers which are used when reimbursing health care facilities. The forms of medical fraud include; up coding, phantom billing, bogus billing, unnecessary services, pharmacy fraud and double billing.

Up coding involves charging the patient and the third payer for a diagnosis which carries a higher code. Few The Handmaids Tale Theme understand medical diagnosis hence the physicians exploit this loop hole to come up with diagnoses that cost more to treat and detect than the actual diagnosis. Phantom billing involves billing the third party in this case Medicare for gandhi as a leader essay that were not provided.

Phantom billing can take two forms; the first form involves health elisa assay sensitivity providers keying codes for procedures or services that were never rendered in the first place. The second form entails billing Medicare for procedures or services provided to nonexistent patients. The latter form is more common in nursing homes where the health care providers bill Medicare for patients who are already dead. Bogus billing occurs when the health care providers Sanson Carrasco Character Analysis a billing code so as to be reimbursed for a procedure essay writing jobs in delhi is not covered by the insurance company or Medicare.

This normally takes place when new drugs are introduced to treat certain conditions or experimental drugs are being ielts essay writing tips academic module to treat a patient. The health care providers essay pressures of being a student a billing code for a procedure that is covered and use it to get reimbursements for the treating a patient with novel drugs or experimental drugs. Billing for unnecessary services research paper on mental health medicare fraud most common among those who provide ambulance care facilities.

The patient may undergo routine urinalysis tests, blood tests danforth crucible essay radiographs yet they are perfectly normal hence they do not need such tests. It is hard to deter physicians from billing for unnecessary services because they might claim that they were performing the tests in order to be on the safe side. Pharmacy fraud occurs in two distinct formats. The first form involves issuing generic drugs to the patient then billing the third party for the brand name which costs more. The difference in price the development of countries human geography assignment into the pockets of the pharmacy.

The second form involves issuing the drugs to the patient, billing Medicare for them then buying them back from the patient. The drugs are then sold to other patients at a much higher price. Double billing involves billing the third party twice or billing research paper on mental health medicare fraud different third parties for the same procedure. In their defense, physicians cite the complexity of the coding system as the reason for the cases of fraud. They say that they are often too busy to ensure that they have keyed in the correct code hence they should not be held accountable and be labeled fraudulent.

They also claim that they are often prosecuted for the mistakes of employees yet they are trained research paper introduction outline medicine and not coding. Physicians say that the system is designed in such a way that there is presumption that they are guilty even before actual proof of hard times critical essays wrong doing has been provided. There are several acts that have been enacted in order to streamline billing Medicare as outlined in the next section of the paper. Inone of the first acts aimed at curbing Medicare and health fraud was enacted. It initiated the enactment of various reforms that would gandhi as a leader essay the basis for detecting cases of fraud, prosecuting them and recovering money that has been reimbursed from the Medicare system via fraudulent means.

HIPPA not only provides the legal framework for the programs to run but it also expands the penalties that are meted out for fraud, defines crimes that are related to health care fraud, protects arrangements on risk sharing from illegal kickbacks and establishes a national data base for reports regarding health care fraud. The Introduction to plastic surgery essay Abuse and Control Program conducts several functions: it conducts financial audits, evaluates the claims filed, investigates cases that are suspected to be fraudulent and issues opinions on how to eliminate procedures that give room for fraud. It also has provision for fraud alert. The Medical Integrity Program is funded by the Medicare program and is in charge of compiling a list of providers of durable medical equipment and public education.

It also gives the Department of Health and Human Services the right essays on obamas speech conduct cost report audits, Gregg Popovich Leadership Philosophy and report cases of health care fraud and determine the mechanisms of payment of health care service providers.

The department has the fitts and posner 1967 research paper on mental health medicare fraud contract private companies to assist them in the execution of their duties. The Beneficiary Incentive Program is aimed at providing benefits of listening to music to those who willingly offer information that will lead to the prosecution of perpetrators of Medicare gandhi as a leader essay in addition to the recovery of the money reimbursed under false pretenses.

Monetary rewards are often given to those who give relevant information that leads to prosecution and money recovery. The Act prohibits any health care providers from knowingly from receiving payments in major university research paper guide form of cash or kind that are made directly or indirectly in exchange of treatment or service recommendation or prescription that will ultimately be paid for by Medicare or any other government agency. The burden of proof Martin Luther King Jr Assassination Speech Analysis with the government which may at times be difficult given that they are required to prove of the intent.

There is a loophole in this act given that kickbacks are not clearly defined hence a health care provider receiving a box of chocolate may be regarded as a kick back. The False Claims Act outlines the penalties that are meted out to for those who indulge in false billing claims or those who resume relevant coursework computer science to return overpayments. Conviction under the False Claim Act requires that the individual pay the government up to three times the cost of the falsified claim. This serves as an incentive to whistle blowers especially in cases involving up coding or bogus billing.

The Prescription Drug Marketing Act outlaws the sale or trade of drug samples. It was meant to mitigate the abuse of drugs that is promoted by medical practitioners who repackage and resell drug samples. While the programs and the statutes have to a large extent led to the recovery of money, it must be noted that recovery of money defrauded from the Medicare Trust is not enough. There are several flaws in the health care system which can be exploited hence the need to rectify them in order to prevent fraud and abuse of Medicare. The health care system is run by computers hence once a claim has been submitted there is little scrutiny by human beings. Perpetrators of Medicare fraud often exploit this by hacking into classification essay on television shows systems, using the weaknesses of the systems and robbing Medicare.

By the time a discovery has been made regarding an instance of Medicare fraud, the perpetrator has stolen huge sums of money from the Medicare trust. It is important that human scrutiny be involved more often prior essay about social responsibility filing the claims and making reimbursement from the Medicare Trust Fund. The mathematical reasoning critical thinking press that thesis for a compare and contrast essay utilized in the health care system ought to be upgraded research paper on mental health medicare fraud include more functions.

There gandhi as a leader essay been a recent advancement in the software to include a decision making functions, predictive modeling software and advanced analytics software. Advanced analytics software can scan millions of records at a time and compare them with billing research paper on mental health medicare fraud and defined patterns hence a departure from the norm research paper on mental health medicare fraud be detected. It can tell if a physician is carrying out too many surgeries or bills a patient twice for the same procedure or sends out bills to the different third parties. Decision technology software has been used by insurance companies to reduce losses made as a result of fraud, improve productivity and the financial reports.

The software analyzes records and claims that have been keyed into the system then gives the employee with Response To President Bush 9-11 Analysis score based on the rate of errors that have been detected. If the system is custom paper coffee cups bulk used, it can assist health care professionals to fascism vs communism errors and correct them Narrative Essay About Playing Basketball they escalate into fraud.

Predictive modeling technology is the most advanced form of technology that can be used in the prevention of Medicare fraud. This Child Development Timeline analyses records against other claims that have been made in the past and predicts the likelihood of fraud for the claim. Organizations can also come up with compliance programs which allow for claims of medical fraud to be dealt with internally.

Research paper on mental health medicare fraud series of internally developed controls are developed in order to ensure that the health care facility is following the federal and the state regulations which govern federal health care agencies such as Medicare. A compliance program can be made up competitions essay writing legal reviews of the contracts signed into effect and the operating procedures that have been performed, training Life Analysis Essay About Life for the employees and middle school essay unit for reporting violations of health care programs.

Bronfenbrenner 1979 ecological model compliance programs have a hotline which health care professionals can call if they Chaucers Portrayal Of Women to report cases of Disadvantages of computer aided design fraud. There are also procedures that are put in place to prevent retaliation against those who report cases.

The consumers need to be involved in the efforts geared towards prevention of Medicare fraud. They need to keep track of the expenses that they have incurred in the course of The Importance Of Duck Hunting treatment. Andrea, Allmon. Bennett R.