The cloud is a Medicaid agency’s strongest new ally against healthcare fraud

Cloud cannot solve healthcare fraud, waste and abuse. But it can provide a flexible infrastructure for coordinating with stakeholders to build strong cases.

By | 4 minute read | August 3, 2021

Medicaid program integrity investigator considering cloud technology

Fraud schemes that target healthcare systems are creative, and it requires just as much creativity to uncover them. Too often though, governments can’t act on their ideas to catch bad actors or wasteful spending because the tools and resources they’re working with aren’t flexible enough to quickly bring those prevention tactics to life. As a result, Medicaid agencies miss out on opportunities to disrupt healthcare scams, curb overspending and uncover potential fraud.

Now, you might be curious how cloud technology can possibly change that. But first, let’s look at how the federal government and state governments in the United States are currently operating. Many rely on program integrity investigators to defend taxpayer-funded programs like Medicare and Medicaid. These investigators spend a lot of time working with data. How easily they can work with data affects how well they can uncover fraudulent claims and other common types of abuse. Right now, many program integrity officials rely on legacy storage technologies to manage their data. Integrating a new data source or adding a new analytics tool can be a painful, months-long process.

By migrating these workloads to cloud and embracing cloud native tools, Medicaid agencies can strengthen their program integrity efforts. Here’s how:

1) More data flexibility

Cloud technology makes it easier to bring different types of data together and integrate them in meaningful ways. Say a program integrity investigator wanted to target fraud schemes or waste related to prescription drugs. They could incorporate records from a prescription drug monitoring program or other electronic medical record systems to determine if there are any healthcare providers who are over-prescribing opioids or other medications. Even if those records require a special clinical data ingestion process and a new clinical data model with unique software requirements, cloud technology makes it convenient to create separate virtual machines that can be connected together and enable flexibility to access different data types easily.

2) Better access to useful tools

Cloud environments provide easy access to many useful data science and analytic tools. Most cloud providers offer marketplaces with pre-packaged algorithms, reporting solutions and other analytics services that can help uncover valuable trends in data. There are even Medicaid-focused algorithms that can help target common types of healthcare fraud or waste, such as unbundling, upcoding, and questionable medical equipment charges. If your program integrity analytics data is in the cloud, you wouldn’t have to worry about whether your server or operating system is compatible with these tools. You can just set up a connection to their service and use the tool as often or as little as you need it.

See the algorithms: Recover payment dollars with key fraud, waste, and abuse algorithms

3) Faster onboarding timelines

Cloud technology not only helps you bring different types of data together and gives you convenient access to tools, it also can help accelerate usage of these tools. With many legacy systems, onboarding a new analytics tool or piece of software can take months. A lot of that time is spent making sure different pieces of software and operating systems are compatible with each other. Cloud technology removes many of the compatibility issues so program integrity leaders can test a new idea or bring a new tool online in weeks instead of months.

4) Simplification

Because cloud technology, especially hybrid cloud technology, is so good for bringing different tools and data types together, it can help simplify your program integrity workflows. Rather than having to manage several separate tools and logins, a cloud solution can help you bring those tools together into a single platform that makes them much easier to access and helps make program integrity investigators be more efficient.

5) Straightforward costs

One of the biggest advantages of cloud technology is reduced infrastructure costs. Rather than maintaining servers or systems on your own, that maintenance would be provided by your cloud provider as a part of its service. When the cloud provider is responsible for maintenance of all your IT infrastructure needs, you could then redistribute your agency resources toward other program integrity analytics and recovery efforts.

By itself, cloud technology cannot solve healthcare fraud, waste and abuse. But it can provide a more flexible infrastructure for coordinating with law enforcement, the attorney general, health insurance companies, the Centers for Medicare & Medicaid Services, and other stakeholders you need to work with to build solid fraud cases. If you’re convinced and ready to give cloud technology a try, consider doing a small proof-of-concept project first and don’t be afraid to try multiple vendors. Each provider has their own strengths, and you want to choose one that helps your program integrity investigators be just as creative as the bad actors they’re looking to catch.

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Read: Government agencies around the world get started with their cloud journey