Thursday, February 22, 2024

Utilizing Technology to Harness Disparate Data Is an Investment in Long Term Fraud Prevention

FedHealthIT CEO, Susan Sharer, recently chatted with Amanda Warfield of Optum Serve about the ways agencies can decrease fraud and waste through a comprehensive data strategy.

Federal agencies need a clear data strategy with specific goals for integration and results 

Federal agencies rely on data for identifying, analyzing, and predicting fraud, waste, and abuse trends. This data is the core of any program integrity strategy; however, challenges arise when information is stored in silos with no centralized access.  In order to effectively apply advanced techniques such as machine learning and predictive analytics, information must first be available in one repository.

The issue sounds concrete on the surface, yet agencies are overwhelmed with the complex path to devising a clear data strategy serving all stakeholders. Commercial organizations like Optum Serve also face similar challenges and have leveraged a cohesive data strategy to help tackle it. Here we have outlined the basic steps, applicable for any public or private organization with a need to centralize data effectively:

  1. Develop a clear plan. With a clearly defined roadmap, understanding of existing data sources and the path to integration, agencies can save time and money.
  2. Implement data governance. Managing data sources that often fall under separate agency centers or groups can be challenging. Having a data governance approach to manage availability, usability and integration of data will provide a framework for an enterprise data strategy.
    1. Develop rigorous data quality. Accuracy and quality of data is critical to ensuring downstream processes such as claims payment decisions or improper payment analyses are correct and timely.
    2. Ensure consistent data availability. Availability of data is important to allow easy access and consumption to support various program integrity business functions.
    3. Improve data usability. To ensure agencies can effectively use their data, it must be clearly structured, labeled and easily searchable and compatible with various analytics and business intelligence tools and technologies.
    4. Ensure data integrity. Throughout data transformation and conversation processes, data must retain integrity to ensure accuracy across various systems and platforms.
    5. Data security. Data must be categorized based on sensitivity, protected from data loss, with managed access granted only to those that need it.
  3. Provide centralized data access across the organization. After a data governance framework is implemented, agencies can provide centralized data access to all users through various interfaces, tools and technologies that support analytics, fraud prevention and other critical work.

Federal Use Case Harnessing Disparate Data

Data is critical to any agency, but especially in Medicare where ongoing fraud challenges impact program funds. Optum Serve has partnered with CMS for more than a decade, supporting fraud, waste, and abuse (FWA) data integration and analytic tool access. By successfully integrating and centralizing data, the Centers for Medicare & Medicaid Services (CMS) implemented advanced fraud prevention predictive analytics and technologies. Without centralized access to data across the enterprise, CMS faced duplication of data leading to discrepancies, rising costs, and maintenance. As a result, accurate visibility into FWA trends was impacted making it difficult to collect evidence against providers found to be fraudulent.

With a focus on recovering funds as part of the One Program Integrity (PI) program, CMS established and maintained a data strategy and platform designed to support program integrity initiatives. The result over two decades is billions of dollars recovered. Additional benefits include:

  1. Creating new ways for CMS to analyze data including data quality and governance, predictive modeling, machine learning, business intelligence, security, and compliance
  2. Expanding and upgrading systems to incorporate new data sets, system capabilities and data analysis tools
  3. Provide analysts access to a suite of analytics and business intelligence tools that access Medicare, Medicaid, provider, beneficiary, and supplementary data to fight FWA

A Global Approach to Data

The Federal, private, and commercial sectors all face similar challenges in the need for access to data from disparate sources.  For instance, the Veterans Affairs (VA) may need access to various data sources, not just internal departments but also financial data from the Internal Revenue Service (IRS) or an outside commercial fraud risk organization when determining Veterans’ benefit eligibility. Merging this data in a timely manner helps the VA increase accuracy of decisions, saving time and dollars. In the commercial space, organizations like Optum Serve have integrated disparate data into centralized repositories using key data sharing and automation technologies.

Being Proactive Saves Reactive Dollars

As evidenced in the CMS use case and Optum’s commercial examples, the investment in developing a clear data strategy pays dividends today and into the future. Deploying such technology can centralize critical data sources, improve timeliness and accuracy of data, and improve program integrity and return on investment overall. Informed decision making across sectors not only saves time and dollars, but ultimately ensures affordability of plans and healthcare for everyone.

About Amanda Warfield

Amanda Warfield currently leads Optum Serve’s program integrity practice, overseeing support and integration of key IT capabilities and solutions for federal agencies. Amanda has worked with federal government clients for more than a decade in designing and implementing approaches to tackle fraud, waste and abuse with an emphasis on innovation and operational efficiency.

About Optum Serve 

As the federal health services business of Optum and UnitedHealth Group, Optum Serve offers federal agencies the robust health IT solutions that have proven successful at one of the largest health care organizations in the world — UnitedHealth Group. Our unrivaled health care knowledge combined with our end-to-end technology allows us to be a unique and reliable partner.


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FORUM Editor
FORUM Editor
Content Analyst for FORUM and Author on the Daily Take Newsletter for G2Xchange Health and FedCiv.

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