How Link Analysis Can Help in Health Care Fraud Investigations
It’s the age of big data. We’re all drowning in it. And while everyone is talking about it, not everybody understands or uses it. So it’s not surprising that the health care fraud investigations industry is still not yet taking full advantage of the opportunities for detection that big data can provide. But the move is under way, and the possibilities are enormous, especially through the use of link analysis.
The main problem with mountains of data is that it all has to be filtered to be used, explains Boyd Bryant, Investigations and Intelligence Expert at Computer Evidence Specialists (CES) “Because everyone is drowning in data, they need to be smart about how they are handling that data,” he says. “The goal is to come up with a finding, some form of knowledge about that data.”
And that’s where link analysis can help. Link analysis can be used to evaluate connections or relationships among organizations, people and transactions. It can be a powerful tool to pinpoint connections linked to health care fraud and reduces drastically the time and effort required to sift through data to find the connections that can lead to the exposure of health care fraud.
How Link Analysis Works
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“Link analysis tools are intelligent enough that a single click of a mouse on a person might give you the house, the mortgage, social networking links, public government records. It might tell me how many limited liability companies he’s got,” says Bryant. By doing something as simple as searching the corporate address, an investigator might uncover the fact that there are 100 different companies registered to it.
“What you wind up with is a visual that allows you to navigate through these mountains of data and be able to tell the story very quickly,” says Bryant. “In the best cases, if an investigator is empowered with those tools, then as they make investigative findings they can embed their findings within this link chart. Now when I walk into the prosecutor’s office trying to get them to prosecute someone criminally, I have a device that will let me tell the story and get to the bottom of whether it is a persuasive enough story to advance the case very quickly. That overcomes all of the initial mental resistance.”
Getting prosecutors to pay attention to insurance fraud cases can be challenging, Bryant explains. “When we go to the criminal courts we may be meeting a prosecuting attorney who is dealing with a serial killer case, or a serial sex offender case, or a gang situation. When they see white collar crime, in a lot of cases they see the complexity of all the documentation. If we can’t help them see the full story very quickly, our case may typically languish for years, not months, before it gets action.”
In the same way that big data leverages the big picture to uncover fraud, Bryant sees a lot of value in eliminating the barriers between the people working in health care fraud too, so that they can share information that might reveal linkages between their cases and experiences.
“If they’re in a traditional, functional vertical-type management organizational structure, meaning that there’s a group that manages pharmacy claims, a group that does initial claims processing, audit, marketing, an investigation unit, etc, we need to find ways within these large companies to fuse all the products together,” he says.
“In my investigations career it was clear to me that if people didn’t work in individual offices, and instead worked together, there were 'eureka' moments where all the pieces fell into place,” says Bryant. “People develop alliances with people who answer to different chains of command. Information is readily shared. You develop a collective mindset and there is greater clarity of how the information is flowing across a company and where work is happening in a redundant fashion,” he says.
“If we can have a nerve center that not only includes the technological systems but also has an overlap of different disciplines of people, we’ll catch a lot more people and we’ll catch them more quickly.”