How data-crunching is cutting down on massive health-care fraud

There are no high-tech forensic gadgets or state-of the-art surveillance devices in Dr. Mike Cohen’s work station here. The federal investigator’s “office” appears about as exciting as an insurance company cubicle.   

But Dr. Cohen is at the cutting edge of a law enforcement innovation that is helping federal agents level the field in the fight against large-scale health-care fraud. 

“No other reporter has ever seen this,” he says, tapping out a command on his computer keyboard. “But just to give you an idea of the metrics we look at.…”

Line after line of data begins to appear on his computer screen, forming a long list of companies and addresses with columns of related measures and rankings assigned to each business.

“Your standard pharmacy that is just billing Medicare is going to be $300,000 to $1.5 million,” Cohen says. “Maybe $3 million if you have a really intense population.”

Cohen scrolls through the list on his computer screen. Nine pharmacies at the top of his list show Medicare billing of $100 million or more.

“We are not talking about a couple of prescriptions here that are out of sorts,” he says.

Not long ago, it would have taken an entire squad of health-care fraud investigators a decade worth of shoe leather to connect all the dots and compile such a list, Cohen says. Today, he can do it in a few seconds. 

“There is no shortage of ways we can twist and crunch numbers to look for targets,” Cohen says. “And there is no shortage of targets.”

Health-care fraud has become a big, lucrative enterprise in the United States. No one knows the full extent of the drain on Medicare, Medicaid, and private health insurers. Experts suggest it may cost $100 billion each year.

Whatever the actual loss, fraud diverts critically needed resources from patient care, undermining the ability of the government and others to help those most vulnerable. 

For decades, federal agents have struggled to keep pace with growing numbers of…

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