Case Study

Data analytics to combat medicare fraud

Stroz Friedberg is a specialized risk management firm built to help clients solve the complex challenges prevalent in today’s digital, connected, and regulated business world

Data analytics to combat medicare fraud

Stroz Friedberg was brought into an investigation of fraud against Medicare by certain doctors who were believed to be overbilling the government.  Specifically, these doctors were suspected of improperly submitting separate claims for medical procedures that were part of the same examination, thereby inflating the amount of money they would collect from Medicare.

In order to pursue the investigation, millions of old billing records had to be analyzed in a cost-effective way.  This was made difficult because the records were stored on legacy-era backup tapes.  The data from those tapes would have to be restored and converted into a format that would allow for data analytics to be performed and then try to pin-point any suspicious claims.

Using our investigative and technical expertise, Stroz Friedberg identified, purchased, and configured the hardware needed to read the backup tapes, which were decades old. Reading the backup tapes was only the first part of the challenge as the tapes contained thousands of variable-length entries encoded in an old data standard known as EBCDIC. Stroz Friedberg worked with a COBOL specialist to transform the data into a more contemporary and suitable SQL database that would allow for the planned analysis efficiently.

Stroz Friedberg then developed data queries to test the government’s theory that certain doctors were improperly submitting separate claims for medical procedures that were part of the same examination. By drawing out key attributes contained in the billing data, we identified instances in which multiple claims to Medicare were being submitted by the same doctor for the same patient within a short time frame. In order to highlight suspicious claims, Stroz Friedberg performed comparative data analysis to identify, among other things, doctors that submitted a higher number of claims than others in the same specialty.  This analysis proved the truth of the allegations and contributed to the conclusion of the case.

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