Using data mining techniques to find fraud is not new. The Medicare Fraud Strike Force has been using these analysis techniques - along with trend evaluation and modeling - for some time. During a speech at the Los Angeles Health Care Fraud Prevention Summit in 2010, for example, Lanny A. Breuer, Assistant Attorney General for the Criminal Division, told the audience that:
And the big data analysis techniques are working. In 2012, several individuals allegedly involved in a $375 million home health fraud scheme were indicted in the Northern District of Texas. HHS Inspector General Daniel Levinson commented that they were discovered by the use of "data analysis [allowing the investigators to] target suspicious billing spikes." Levinson explained that, “[i]n this case, our analysts discovered that in 2010, while 99 percent of physicians who certified patients for home health signed off on 104 or fewer people Dr. Roy certified more than 5,000."
But, with the release of the Medicare billing data to the public, now plaintiffs' lawyers have access to the data as well. Given the possible recoveries, it's no surprise:
As explained by Reuters, the whistleblower lawyers are doing the same thing that the government is doing in it's analysis - looking for doctors whose billing practices are outside the norm to bolster existing cases:A whistleblower who prevails gets up to 30 percent of whatever the government recovers, and 40 percent of that reward typically goes to the whistleblower's lawyer.
In undertaking this analysis, however, attorneys are likely find new cases. Additionally, practice managers, pharmaceutical sales managers, nurse practitioners, and others who have a suspicion that something may be amiss in a practice, with their employer, with a pharmaceutical relationship, can now themselves use the database to investigate. This data release will likely lead to additional healthcare fraud cases and bolster whistleblower claims.By Thursday, Pennsylvania lawyer Marc Raspanti was having a ball. Raspanti said he spent six hours combing through the data. He has several Medicare fraud lawsuits pending against pharmaceutical companies alleging kickbacks to certain doctors.
 Press Release, Department of Justice, Assistant Attorney General for the Criminal Division Lanny A. Breuer Speaks at the Los Angeles Health Care Fraud Prevention Summit, Speech, Aug. 26, 2010, available at https://www.justice.gov/criminal/pr/speeches/2010/crm-speech-100826.html (last visited April 19, 2014).
 Press Release, Department of Justice, Dallas Doctor Arrested for Alleged Role in Nearly $375 Million Health Care Fraud Scheme, Feb. 28, 2012, available at https://www.justice.gov/opa/pr/2012/February/12-crm-260.html (last visited April 19, 2014).
 Terry Baynes, Lawyers Start Mining the Medicare Data for Clues to Fraud, Reuters, April 14, 2014, https://www.reuters.com/article/2014/04/14/us-data-idUSBREA3D05820140414.
Posted by Tatiana Melnik April 19, 2014.