Examining the role of data and analytics in fighting fraud, waste, and abuse

On June 7, 2016, a podcast interview of Dr. Caryl Brzymialkiewicz, Chief Data Officer for the HHS Office of Inspector General (OIG) was made available by the OIG. In the podcast, Brzymialkiewicz provided insight into how the OIG uses data and analytics to reduce healthcare fraud, waste and abuse.

The Chief Data Office officially came into existence last year, but the OIG’s advanced analytic team has been around for several years. Brzymialkiewicz indicated that her office is currently focusing on: (1) how to accelerate the work of the advanced analytic team; (2) how to help the OIG to become even more effective and efficient; (3)  improving access to data; (4) supporting OIG investigators in their cases, with audits and evaluations, and in determining what other datasets they need; and (5) making sure the data the OIG has is high quality data. One current example of the office’s focus is its work with CMS as it creates a new nationwide Medicaid data set. According to Brzymialkiewicz, “we’re working closely with [CMS] to understand, as they’re implementing their new system, what does [it] mean, [and] how can we potentially tap into that environment.”

Brzymialkiewicz defined advanced analytics as “having high quality lead-generation for either our investigators, our auditors, our evaluators or for compliance oversight.” According to Brzymialkiewicz, advanced analytics data can either lead to someone that is potentially committing fraudulent activity or OIG investigators can bounce information from a hotline call or from a whistleblower  against the data to help make a case of fraud.

Brzymialkiewicz described her office’s predictive analytics space, where they use statistical models to generate risk scores. These scores can result in a pharmacy or provider being designated low, medium, or high risk. She opined that for high risk entities the OIG might want to apply a little more scrutiny. She indicated that her office plans to accelerate their predictive analytic work.

With regard to internal support at OIG, Brzymialkiewicz stated that her office is working to support senior leadership, to help inform their decisions, to facilitate the right conversations about where to allocate resources, and to help position the OIG to compete for increasingly scarce resources across the entire government.

Her office is heavily invested in developing additional tools to fight fraud, waste and abuse. She described the development process as one of trying to democratize data, so that rather than requiring the whole organization to understand programing language, investigators will instead have easy-to-use tools in their hands to accomplish their goals.

Finally, she described the need for link analysis to determine the possible connectedness between providers. According to Brzymialkiewicz, this would allow the OIG to look at providers that have high risk scores to see how they are connected to other entities that may also be committing fraud.