Big Data Analytics Emerges as a Powerful Weapon Against Healthcare Fraud

Nowadays, it is becoming increasingly important to be vigilant against and prevent healthcare fraud.

With breakthrough advancements in technologies such as online health records, remote patient care, and big data-based health management, the healthcare industry is undergoing a profound transformation. The current changes bring us a more efficient healthcare system, improved diagnostic and therapeutic outcomes, and enhanced economic benefits; however, if these changes are not properly addressed, we will face a series of challenges: skyrocketing healthcare costs, breaches of personal privacy, and even risks to patients’ lives.

The Association of Certified Fraud Examiners (ACFE) considers 2015 to have been a year in which technology exacerbated fraud crimes. However, while technology has made fraud cases more complex, it has also provided institutions and government investors with powerful tools for detecting and preventing fraud. The ACFE believes that big data analytics is becoming the preferred approach to combating healthcare fraud, with the most significant application of analytical tools being the extraction of actionable insights from dispersed, unstructured data.

As complex data analytics tools become increasingly accessible and user-friendly, big data analytics will effectively safeguard patient privacy and reduce fraudulent prescriptions.

Data Analysis to Prevent Privacy Breaches

The past year was a dark one for cybersecurity. Data breaches at Sony, Target, and eBay have raised public awareness about the protection of sensitive information. However, healthcare organizations have proven largely powerless against such cyberattacks. In fact, a 2014 analysis by BitSight Technologies of S&P 500 companies indicated that healthcare and pharmaceutical firms faced significantly worse cybersecurity challenges than retailers, due to poor security performance and sluggish response times.

For healthcare organizations committed to safeguarding the security of patients’ medical information, data is the most effective tool. Data not only enables the management of security issues and the prevention of fraud and compliance violations, but also allows for the prediction and proactive mitigation of such risks.

As the landscape of medical health and safety evolves alongside compliance requirements, healthcare organizations must respond swiftly to information security issues. This necessitates an open approach and methodology, as well as the ability to detect anomalous individual data points hidden within records, sensor data, and machine-generated data.

Collecting, preparing, and analyzing these fragmented data entails a substantial workload; however, advanced data analytics have made such cumbersome tasks significantly more manageable. By enabling healthcare organizations to transcend constraints related to resources, variety, volume, and format, data analytics facilitate the rapid integration, consolidation, and analysis of data, as well as the identification of solutions for fraud and compliance issues. Consequently, data analytics play a decisive role in this silent battle.

For instance, organizations can anticipate threats at an early stage by analyzing public websites, tracked pages, and application programming interfaces (APIs), or monitor abnormal server access patterns and implement security maintenance functions by analyzing log files.

Data Analysis Reduces Prescription Drug Abuse

Data analytics can not only protect patient information but also save patients’ lives. According to data from the Centers for Disease Control and Prevention (CDC), more than half of the 43,982 deaths caused by drug overdoses were related to medications, and the misuse of these prescription drugs costs the nation $55 billion annually. If physicians and pharmacies could access more historical information on controlled substances during clinical care, they would be able to make better prescribing decisions and identify potential prescription drug misuse issues.

Pharmacies, physicians, and hospitals can leverage diverse data resources to analyze and rapidly disseminate information, enabling the tracking of anomalous activities to reduce prescription drug misuse. Recently, California launched a Prescription Drug Monitoring Program (PDMP) that allows healthcare providers to prescribe and dispense controlled substances while accessing patients’ historical data in real time. A growing number of states are advocating for the use of secure databases that employ big data analytics to monitor fraud and abuse. Big data analytics tools streamline processes and deliver user-friendly data, making big data accessible not only to scientists but also to broader audiences. Rather than merely transmitting raw data to healthcare experts, sophisticated databases like California’s PDMP present clinicians with insights into the causes, locations, timing, and mechanisms of such incidents.

Data analysis plays a crucial role in combating healthcare fraud. As more institutions adopt analytical tools to make big data accessible to everyone, big data analytics will benefit all areas of healthcare.

Original author of this article: Stefan Groschupf, CEO of the big data analytics company Datameer