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Using Data Effectively & Creatively to Protect Our Elderly Population

Exploring the Root Cause of Medicare Claims Fraud

Interoperability has become the new buzz word within healthcare.  The goal is admirable: use computer systems to easily exchange data.  It sounds so simple.  We are even at a place with machine learning and artificial intelligence where all kinds of information can be easily shared.  So it makes me stop to think, why is Medicare fraud still so prevalent.  If we are sharing information and we can detect patterns, then why are we still having this issue.  It seems that the answer lies in the fact that while the capability exists, the willingness to share data across the right platforms still is not being done.  One carrier may have data within its organization while one regulatory body may internally share information and on the other hand providers respectively share information among one another.  Yet, if the American healthcare system is not a system at all, in that all the parts do not integrate, then it follows that the only way for the concept of interoperability to work then a level of transparency is required.  If those entities don't share information with each other, then the patterns of waste and abuse across organizational lines will never properly be discovered.  Why does this matter?  It is our elderly population that pays the high cost of deceitful fraud cases.  Those costs get eaten up by provider and government who provide and subsidize care respectively.  While the mystery of fraud increases, so does the amount our elderly pay as a direct result.

A Data-Driven Solution is Within Reach

This is why I drive every day to push my skills to new heights.  I want to find out is it possible to build a platform across systems, organizations and governments that does not compromise protected health information but does combat fraud.  In such a system, data would tell a story that would undeniably stop fraud in the Medicare space but could be duplicated across healthcare and reach into other industries as well.  This model would mean an increase in dynamic relationships and a would equally require a paradigm shift in how we perceive healthcare withing our capitalistic world.  Yes, this is veering toward that taboo word: impossible.  Yet, to the generations that came before, don't we owe it to them?  Is it at least worth discussing?  Can we sit down on all of the data that is available and look them in the eye and say, "It simply can't be done?"  I, in good conscious, cannot.


The Vision

So what is the plan?  That is the question of the hour.  Day by day and moment by moment, I am looking to learn about technology and have conversations with experts to explore this solution.  When we're done, I want to have an application that can connect sources of healthcare data to quickly identify and eliminate fraud.  This is one of my sole purposes for being in the healthcare space.  I want to make a difference and I believe with a little work that I can.

Will you join me?

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