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Does the Department of Justice Health Care Fraud Unit Use AI?

Department of Justice logo with US marshals on the symbol as well.

Does the Department of Justice Health Care Fraud Unit Use AI?

What is the HCFU (and Does it Use AI?)

The Health Care Fraud Unit develops criminal cases. As far as we know it does not yet use Artificial Intelligence (AI) but it does complex data analytics and algorithms based upon criteria that are not disclosed. We can be reasonably certain that they take a range of values and eliminate the outliers to identify norms. The norms would be items such as billings per patient, DME prescriptions per patient and other “per patient” data. Variations can be geographic and perhaps other confounding variables can be input. At a certain deviation from the mean a closer review of the medical practice or physician may commence. The unit prides itself on uncovering newly emerging health care fraud schemes so the pattern search must be looking for deviations from non-law enforcement based sources e.g. billing and diagnostic data. We are confident that algorithms based upon prosecuted cases are also in the mix.

The Strike Force Coordinates Multiple Units

A HCFU strike force spreads enforcement to nine geographic centers. These centers coordinate in agency sections such as the Fraud Section, Federal Bureau of Investigation, U.S. Department of Health and Human Services-Office of the Inspector General, Centers for Medicare & Medicaid Services, Drug Enforcement Administration, Defense Criminal Investigative Service, Federal Deposit Insurance Corporation-Office of the Inspector General, Internal Revenue Service-Criminal Investigations, Department of Labor-Office of the Inspector General, United States Postal Service-Office of the Inspector General, Veterans Administration-Office of the Inspector General, and other agencies.

The HCFU is Profitable

This unit is extraordinarily profitable. They are the largest trial unit in the Department of Justice in terms of numbers of trials. The dollar amounts at stake are in the billions although actual recovery is much less than the preventative effect of stopping future fraudulent billings.

The danger to a medical practice is that this unit is so powerful and so well financed that like the “Borg” in Star Trek, resistance may seem futile. Physician defense lawyer Daniel Horowitz is not that pessimistic.  He recognizes that a Department of Justice Health Care Fraud Strike Force investigation is a frightening and career threatening event but there are defenses and not every case results in a conviction.   We can see how their software will likely use true AI in the future.  At present the nature of your practice can skew results so that you are over included and unfairly investigated.