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Is Artificial Intelligence (AI) Investigating Doctors?


Is Artificial Intelligence Investigating Doctors?

Is there an Artificial Intelligence investigation tracking doctors? Is there an AI bot combing your financial records, billings, IRS filings and internet searches reporting back to some government controlled cabal? There answer is “yes”, well “sort of”, well, “it is getting there”, well “it’s true in part”.

AI is a loose term and there is a huge difference between sophisticated algorithms, machine learning, integration of huge datasets, sophisticated and even machine generated sorting and true self awareness. As far as we know there is nothing approaching an independent machine focus on medical practices. But there is an entity that is compiling huge datasets and employing very sophisticated sorting and balancing mechanisms to extract the identities of physicians and practice groups that should be targeted for investigation.

The Most Sophisticated AI Type Investigative Unit (HFPP)

The Healthcare Fraud Prevention Partnership (HFPP) is a voluntary, public/private partnership. It joins investigative and billing units of the federal government, state agencies, law enforcement, private health insurance plans, employer organizations, and healthcare anti-fraud associations to identify and target healthcare providers and billing entities where fraud, overbilling, over utilization and other “overs” take place.

The HFPP claims to reduce fraud, waste, and abuse across the healthcare sector. However it is not clear that their computers balance health care delivery and effective care vs. identifying outliers and high billers without regard to patient care considerations. In other words it can easily sweep up the good with the bad.

Broad Data Sets

Drawing on huge and disparate data sets such as Medicare, Medi-Caid, insurance, worker’s compensation and other billings the AI type system can compare size of practice, geographic location, prior arrests, prior billing disputes, names of practitioners and other data poionts to identify potential savings to payors. While they consider this a system to reduce fraud, waste and abuse it is not clear that even their claimed “enhanced analytics” can make medical judgments.

An Expansion of Prior Computer Analytics

The use of computer analysis against standardized norms is nothing new. The Centers for Medicare & Medicaid Services’ (CMS) Fraud Prevention System (FPS) data analytic system has for years been used to initiate what they call “corrective actions” against providers. In 2016 CMS reported that 90 providers had their payments suspended because of investigations initiated or supported by FPS. The HFPP however, aggregates data from many additional sources and it is not clear what types of analytics they use as generated by private industry.

The AI (type) May Favor Insurance Companies

This means that the focus of the AI type analytics may be more profit oriented by targeting high billing entities without regard to balancing issues. An example may be a clinic that works in underserved areas. Other clinics may have low billings because of inadequate staffing, inadequate equipment and limited services. A full service center may have higher per capita billing as it provides more on site services and perhaps finds conditions requiring treatment that are missed by less thorough centers. The result can be targeting of “the good guys” as the good guys show up as “overbilling” when compared to other providers with the same patient population and geographic location. In other words, good medicine can look to improperly created partial AI as fraud.

Machine Learning Feedback May Be Biased 

Likewise, in terms of machine learning who tells the computer when its results are accurate? Is an accurate result confirmed by a criminal prosecution or by dollar savings as billings by that entity decrease once they are identified and contacted? The latter can reinforce an insurance reimbursement lowering strategy vs the true identification of fraud or waste.

If you are a medical doctor, medical group or other entity targeted for billing, upcoding, audits or other AI/HFPP or other task force based inquiry our healthcare attorneys can assist you. We have criminal defense specialists, a physician lawyer, an MBA and audit experts to protect your personal and financial interests.