act Abuse is a civil violation where criminal intent cannot be proven In the case of surveys it appears falsification is an abuse of trust There is a difference between fraud and abuse Data ID: 594425
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Slide1
Fraud refers to a criminal act.Abuse is a civil violation where criminal intent cannot be provenIn the case of surveys, it appears falsification is an abuse of trust.
There is a difference between fraud and abuseSlide2
Data MiningDevelopment of specific statistical models (which reflect particular behaviors)Baseline distribution (Spike Models
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Peer Comparison Link Analysis (geographical, professional, beneficiary)Sampling
Statistical Methods Used in Fraud
Detection which Transfer to Detecting Possible
FalsificationSlide3
Organizations have entire departments devoted toward finding fraud.Subject Matter expertsInvestigators
CMS has a fraud detection unit with over 100 statistical models that are run frequently.
Basic Organizational Structure for Medicare/Medicaid Fraud Detection