Tag Archives: data mining

Using Link Analysis to untangle fraud webs

Posted by Douglas Wood, Editor.

NOTE: This article originally appeared HERE by Jane Antonio. I think it’s a great read…

Link analysis has become an important technique for discovering hidden relationships involved in healthcare fraud. An excellent online source, FierceHealthPayer:AntiFraud, recently spoke to Vincent Boyd Bryant about the value of this tool for payer special investigations units.

A former biometric scientist for the U.S. Department of Defense, Bryant has 30 years of experience in law enforcement and intelligence analysis. He’s an internationally-experienced investigations and forensics expert who’s worked for a leading health insurer on government business fraud and abuse cases.

How does interactive link analysis help insurers prevent healthcare fraud? Can you share an example of how the tool works?

Boyd Bryant: Link analysis is most often used to piece together different kinds of data from multiple sources–to identify key players, connections between those players and patterns of behavior frequently missed. It can simplify an understanding of the level of involvement of individuals and criminal organizational hierarchies and can greatly simplify visualizing and communicating the operations of complex criminal enterprises.

One thing criminals do best is hide pots of money in different places. As a small criminal operation becomes successful, it will often expand its revenue streams through associated businesses. Link analysis is about trying to figure out where all those different baskets of revenue may be. Insurers are drowning in a sea of theft. Here’s where link analysis becomes beneficial. Once insurers discover a small basket of money lost to a criminal enterprise, then serious research needs to go into finding out who owns the company, who they’re associated with, what kinds of business they’re doing and if there are claims associated with it.

You may find a clinic, for example, connected to and working near a pharmacy, a medical equipment supplier, a home healthcare services provider and a construction company. Diving into those companies and what they do, you find that they’re serving older patients for whom multiple claims from many providers exist. The construction company may be building wheelchair ramps on homes. And you may find that the providers are claiming payment for dead people. Overall, using this tool requires significant curiosity and a willingness to look beyond the obvious.

Any investigation consists of aggregating facts, generating impressions and creating a theory about what happened. Then you work to confirm or disconfirm your theory. It’s important to have tools that let you take large masses of facts and visualize them in ways that cue you to look closer.

Let’s say you investigate a large medical practice and interview “Doctor Jones.” The day after the interview, you learn through link analysis that he transferred $11 million from his primary bank account to the Cayman Islands. And in looking at Dr. Jones’ phone records, you see he called six people, each of whom was the head of another individual practice on whose board Dr. Jones sits. Now the investigation expands, since the timing of those phone calls was contemporaneous to the money taking flight.

Why are tight clusters of similar entities possible indicators of fraud, waste or abuse?

Bryant: When you find a business engaged in dishonest practices and see its different relationships with providers working out of the same building, this gives rise to reasonable suspicion. The case merits a closer look. Examining claims and talking to members served by those companies will give you an indication of how legitimate the operation is.

What are the advantages of link analysis to payer special investigation units, and how are SIUs using its results?

Bryant:  Link analysis can define relationships through data insurers haven’t always had, data that traditionally belonged to law enforcement.

Link analysis results in a visual reference that can take many forms: It can look like a family tree, an organizational chart or a time line. This reference helps investigators assess large masses of data for clustering and helps them arrive at a conclusion more rapidly.

Using link analysis, an investigator can dump in large amounts of data–such as patient lists from multiple practices–and see who’s serving the same patient. This can identify those who doctor shop for pain medication, for example. Link analysis can chart where this person was and when, showing the total amount of medication prescribed and giving you an idea of how the person is operating.

What types of data does link analysis integrate?

Bryant: Any type of data that can be sorted and tied together can be loaded into the tool. Examples include telephone records, addresses, vehicle information, corporate records that list individuals serving on boards and banking and financial information. Larger supporting documents can be loaded and linked to the charts, making cases easier to present to a jury.

Linked analysis can pull in data from state government agencies, county tax records or police records from state departments of correction and make those available in one bucket. In most cases, this is more efficient than the hours of labor needed to dig up these types of public records through site visits.

Is there anything else payers should know about link analysis that wasn’t covered in the above questions?

Bryant: The critical thing is remembering that you don’t know what you don’t know. If a provider or member is stealing from the plan in what looks like dribs and drabs, insurers may never discover the true extent of the losses. But if–as a part of any fraud allegation that arises–you look at what and who is associated with the subject of the complaint, what started as a $100,000 questionable claims allegation can expose millions of dollars in inappropriate billings spread across different entities.

Investigating the Investigations.

Posted by Douglas Wood, Editor.

A few years ago, I read a book called Fraud Analytics by Delena Spann.  Ms. Spann is with the U.S. Secret Service, Electronic & Financial Crimes Task Force. The book is an overview of investigation analytics with specific information about some former technology leaders in this area.

The IBM i2 toolset is discussed, along with offerings from Raytheon, Centrifuge, and SAS, and FMS’ Link Analytics, and others. (My friend Chris Westphal, formerly of Raytheon Visual Analytics, by the way, published his book ‘Data Mining for Intelligence, Fraud & Criminal Detection’ a few years ago and is another one I strongly recommend.)

Both books offer advice and use cases on how technology can be applied in the fight against crime. A few months ago, I summarized the types of technology being put to use as tools to prevent, detect, and investigate fraud and other criminal activities. (It’s worth a quick read.) What I’m investigating today, however, is… well, investigations.

“IMA is the most critical connection between technology and investigators.”

In my technology summary, I termed this area Investigation Management & Adjudication (IMA). IMA is the most critical connection between technology and humans within an enterprise fraud management ecosystem. Incorporating key elements of enterprise case management, collaboration, link visualization, information dissemination and knowledge discovery, this layer of functionality is designed to uncover insights which aid in investigating complex incidents. The result ought to be actionable visualization of critical entities, and documented results for potential litigation and regulatory compliance.

IBM i2 has long been considered a thought and market leader in this segment – deservedly or not. Palantir Technologies plays in this area as well. Perhaps no company is more in tune with this market, though, than Visallo with their leading investigation analytics platform. Each platform clearly adds value to investigation case management solutions by providing powerful, emerging functionalities that allow easy and intuitive consumption of data in any form. For investigators, the more data – and the easier that data is to consume – the better.

“Users want actionable intelligence, not endless queries.”

What makes for good IMA? A few things, actually. First among them is the technology’s ability to adapt to the way human beings think and act. Users want actionable intelligence, not endless queries. IMA tools, therefore, ought to interact with the investigator in a consultative way that a fellow investigator would. “Hey, have you thought about this, Mr. Investigator?” and “Maybe you should look at that.”

Second, IMA ought to have context. Technologies that simply point to two entities and say, ‘Hey these things look linked‘ are great but leave all of the thinking up to Mr. Investigator. The IMA tools that I like have contextual values associated to those links. ‘Hey, these things look linked AND here’s why that’s important’. Big difference.

Third, IMA should bring the investigations to closure. There are a lot of data mining tools out there that allow querying with case management. How, though, does the investigator get to the point where an investigation is solved and prosecutable? Once again, the most functional IMA products act the way humans do. They package up the results of the investigation in an easy-to-comprehend document that can be shared internally or with police. No loose ends.

“Every investigation ends with an investigator.”

Predictive analytics, big data, and real-time alert scoring are the current industry buzzwords. They should be. They’re important. At the end of the day, however, every investigation ends with an investigator. Putting the right tools in their hands is often the difference between success and failure in an entire enterprise investigation system.

That’s precisely what Crime Tech Solutions, LLC does. Please take a moment to look us over.

Part Two of this series is now available HERE.