Background
During the pandemic, the Centre for Medicare and Medicaid Services (CMS) introduced waivers and rule flexibilities to address rising COVID-19 cases. This included expanding telehealth services to urban areas, along with various testing options such as surveillance testing, school and workplace testing, self-tests, and more inpatient settings such as nursing homes. The federal and state governments also covered COVID-19 testing, vaccination and treatment for the uninsured population, creating opportunities for fraud and unnecessary testing, double billing, kickbacks, and deceased billing, mainly for monetary gain, by unscrupulous healthcare providers.
Aim
The study aims to safeguard the integrity of public health resources as well as government preparedness in the wakeup of future unforeseen crises.
Methodology:
The study adopted an unsupervised learning approach. Using Python programming, the study employed the use of Isolation Forest to detect healthcare providers who had anomalies in the payment for COVID-19, treatment and vaccination by the HRSA. The study also adopted an official search enquiry into official U.S. Government websites such as the FBI, USDOJ, and HHS-OIG for schemes relating to COVID-19 testing and treatment.
Results
The isolation forest algorithm, set at a 5% contamination level, identified 1,890 healthcare providers (7.64% of total claims) as having anomalies. These providers had an average total claim amount of approximately 7.5 million. The highest anomaly claim amounted to 646 million, primarily attributed to “Claims Paid for Testing”. These results support the recommendations given to the HRSA by the Office of Inspector General of the Department of Health and Human Services (HHS-OIG), emphasizing the need for identifying and addressing improper payments.
Conclusion/Recommendation:
Protecting public health resources requires preventing fraud in the healthcare industry. Strong education programs for healthcare workers are crucial, as are vigilant oversight and collaboration between federal and state agencies. Additionally, this study emphasizes how crucial it is to use official government resources—such as the FBI, HHS-OIG, USDOJ, and CDC—to efficiently detect and prevent fraudulent activities. By putting these suggestions into practice, healthcare programs such as COVID-19 testing can be made more reliable, and public health resources will not be misused.