Tag Archives: SAS

Medicaid Fraud – The NAMPI Conference Wrap

Posted by Douglas Wood, Editor.MedicaidFraud-2_jpg_800x1000_q100

The National Association for Medicaid Program Integrity (NAMPI) wrapped up its 31st annual conference yesterday (August 12) in New Orleans with the theme “Jazzing up Program Integrity in the Big Easy.” I’m glad that the conference itself was full of cool presentations and networking events, because the temperature outside was Hot Hot Hot! (Note to self: One ‘Hurricane’ at Pat O’Briens on Bourbon Street is enough.)

50 years after President Lyndon Johnson signed into law legislation creating two new national health insurance programs –  Medicare and Medicaid – the latter is the largest source of medical and health-related services in the US, providing healthcare to over 68 million Americans with a low income. As the number of enrollees continues to grow, so then does the challenge of maintaining program integrity and fighting the inevitable fraud that hurts us all.

As someone who markets technology solutions in the fight against fraud and crime, I found much of the conference to be right up my alley. As with any conference, much of the agenda was sponsored by vendors of data solutions and technology. Kudos to LexisNexis for sponsoring keynote speaker Elizabeth Smart, former kidnapping victim and advocate for children’s safety. Her story was a powerful way to begin the conference and the packed room was riveted by her story and courage.

NAMPI president John McCormick’s Monday morning remarks were short and sweet and set the tone for what turned out to be an excellent couple of days. In particular, I thought the breakout session on program integrity by the US Government Accountability Office was excellent, as well as a session discussing the facts and myths about Return on Investment. The panel included Illinois Inspector General Brad Hart, Ohio’s Lalita Jambhale, and Oklahoma’s Cindy Roberts. A session called Advanced Analytics was also well-attended and, in my opinion, one of the better forums.

There were several excellent vendor-specific sessions as well, most notably a session entitled “The Next Generation of Medicaid Program Integrity: Where Identity Data, Linking Technology, and Clearing Houses Intersect”, and a look at Missouri’s Medicaid Audit and Compliance programs sponsored by Truven Analytics.

A walk around the Exhibitor floor showed most of the usual suspects – HMS, Truven, SAS, IBM, and others. Each vendor had some uniqueness and most had interesting fraud detection and visual analytics. Still missing from the end-to-end solution equation, however, is an investigative case management system that is purpose designed for Medicaid fraud investigations. Most vendors talked a good talk… few could walk the walk in that area. And what about a biometrics play? Identity assurance is a key element to medical care, why not in program integrity? When will someone fill those voids?

Of note, 21CT was in attendance and had, from what I could see, one of the better overall demonstrations. Their Torch offering continues to impress. Also interesting, Appriss‘ continued push into the industry with their ever-growing database of incarceration records. All vendors performed well, and a full list of those sponsors and exhibitors can be found on the NAMPI Conference website.

Congratulations to NAMPI on an excellent conference, and here’s hoping that the ideas shared continue to put a dent in the billions lost to fraud each year.

Part Two: Major Investigation Analytics – Big Data and Smart Data

Posted by Douglas Wood, Editor.

As regular readers of this blog know, I spend a great deal of time writing about the use of technology in the fight against crime – financial and otherwise. In Part One of this series, I overviewed the concept of Major Investigation Analytics and Investigative Case Management.

I also overviewed the major providers of this software technology – Palantir Technologies, Case Closed Software, and Visallo. The latter two recently became strategic partners, in fact.

The major case for major case management (pun intended) was driven home at a recent crime and investigation conference in New York. Full Disclosure: I attended the conference for educational purposes as part of my role at Crime Tech Weekly. Throughout the three day conference, speaker after speaker talked about making sense of data. I think if I’d have heard the term ‘big data’ one more time I’d have gone insane.  Nevertheless, that was the topic du jour as you can imagine, and the 3 V’s of big data – volume, variety, and velocity – remain a front and center topic for the vendor community serving the investigation market.

According to one report, 96% of everything we do in life – personal or at work – generates data. That statement probably best sums up how big ‘big data’ is.  Unfortunately,  there was very little discussion about how big data can help investigate major crimes. There was a lot of talk about analytics, for sure, but there was a noticeable lack of ‘meat on the bone’ when it came to major investigation analytics.

Nobody has ever yelled out “Help, I’ve been attacked. Someone call the big data!”. That’s because big data doesn’t, in and by itself, do anything.  Once you can move ‘big data’ into ‘smart data’, however, you have an opportunity to investigate and adjudicate crime. To me, smart data (in the context of investigations) is a subset of an investigator’s ability to:

  1. Quickly triage a threat (or case) using only those bits of data that are most immediately relevant
  2. Understand the larger scope of the crime through experience and crime analytics, and
  3. Manage that case through intelligence-led analytics and investigative case management, data sharing, link exploration, text analytics, and so on.

Connecting the dots, as they say. From an investigation perspective, however, connecting dots can be daunting. In the children’s game, there is a defined starting point and a set of rules.  We simply need to follow the instructions and the puzzle is solved. Not so in the world of the investigator. The ‘dots’ are not as easy to find. It can be like looking for a needle in a haystack, but the needle is actually broken into pieces and spread across ten haystacks.

Big data brings those haystacks together, but only smart data finds the needles… and therein lies the true value of major investigation analytics.

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.