Building Intelligent Systems for Paying Healthcare Providers and Using Social Media to Detect Fraudulent Claims

Building Intelligent Systems for Paying Healthcare Providers and Using Social Media to Detect Fraudulent Claims

Jack S. Cook (The College at Brockport, SUNY, Brockport, NY, USA) and M. Pamela Neely (The College at Brockport, SUNY, Brockport, NY, USA)
DOI: 10.4018/IJOCI.2017040102
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Abstract

Using an interpretive case study approach, this paper describes the data quality problems in a regional health insurance (RHI) company. Within this company, two interpretive cases examine different processes of the healthcare supply chain and their integration with a business intelligence system. Specifically, the first case examines RHI's provider enrollment and credentialing process, and the second case examines the processes within the special investigations unit (SIU) for investigating and detecting fraud. The second case examines DIQ issues and how social media can be used to acquire evidence to support a fraud case. In addition, the second case utilized lean six sigma to streamline internal processes. A data and information quality (DIQ) assessment of these processes demonstrates how a framework, referred to as PGOT, can identify improvement opportunities within any information intensive environment. This paper provides recommendations for DIQ and social media best practices, and illustrates these best practices within this real-world context of healthcare.
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Literature Review

Healthcare

As defined by the U.S. Department of Health and Human Services, a healthcare provider is “a provider of services as defined in §1861(u) of the Act (Social Security Act), a provider of medical or health services as defined in §1861(s) of the Act, and any other person or organization who furnishes, bills, or is paid for healthcare services or supplies in the normal course of business.” (U.S. Department of Health and Human Services, 2001) Until recently, healthcare providers were paid when sick people sought treatment. Quality and outcomes were not rewarded, but rather providers were paid based on how much was done to treat the patient. In the future, healthcare providers will be given financial incentives to keep people well, and quality, not treatment, will matter a great deal. This shift from volume to value will require a rethinking of treatment plans and a shift towards preventative care.

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