Seeking Student Innovation to Combat Healthcare Fraud

Context of the Competition

The Healthcare Anti-Fraud Academic Competition seeks to discover talented individuals with innovative solutions to assist government and private healthcare payers reduce dollars lost to health care fraud. MITRE is seeking inquisitive students at U.S.-based colleges and universities to team together to develop innovative approaches for ferreting out healthcare fraud, using a dataset and tools provided by MITRE. This challenge is designed to enable students to understand and attack this problem.

• MITRE will provide the data, and teams can select familiar tools already in use for coursework, so there’s no up-front investments needed to participate.
• Competitor submissions will be scored by a panel of experts, with the winning team(s) invited to present their approaches to government and industry experts.

Scores will be based on a mix of outlier and scheme detection coupled with a written presentation. Score tie breakers will be determined based on speed of submission.

How big is the problem? Of the 3.4 trillion dollars spent on healthcare every year in the U.S., the National Health Care Anti-Fraud Association estimates that tens of billions of dollars are lost to healthcare fraud. This loss directly impacts patients, taxpayers, and government through higher healthcare costs, insurance premiums, and taxes. Healthcare fraud has a human face as well—every day the media documents cases involving individuals who are exploited and subjected to unnecessary or unsafe medical procedures or whose medical records are compromised because their legitimate insurance information is used to submit falsified claims.

Why has this not been solved? The healthcare system is complex, offering fraudsters myriad of codes, multiple unconnected reimbursement targets, and a variety of entry points into the system. Fraud schemes quickly migrate from payer to payer and region to region, and as schemes are uncovered and prevented, they morph and are re-introduced. While the government and private industry continue to make progress identifying and preventing fraud prior to claims payment, there is still huge opportunity for new approaches to achieve greater impact.

Who we are:

The MITRE Corporation is a not-for-profit company that operates federally funded research and development centers (FFRDCs) to address challenges and provide innovative, practical solutions across government programs.

Our partner:

The National Health Care Anti-Fraud Association (NHCAA) is the leading national organization in the fight against healthcare fraud. The private-public partnership mission is to protect and serve the public interest by increasing awareness and improving the detection, investigation, civil and criminal prosecution and prevention of health care fraud and abuse.

Challenge Timeline

November 4, 12:00 PM ET: The Competition is open. Teams will have full access to the competition data to perform outlier and scheme detection in health care claims. MITRE will provide a series of example analytics based on common fraud scenarios for teams to check your work as you develop algorithms.

November 7, 4:00 PM ET: Join the MITRE team for an hour-long webinar to understand competition rules, expectations, scoring criteria and key deadlines.  Join below

Join Skype Meeting    passcode:    93226906

or dial in at  (703) 983-2020 ## 93226906#  Slides are available on the reference page.

November 14, 4:00 PM ET: Join the MITRE team experts to ask questions about the data and to learn more about Urine Drug Screen fraud, common schemes, and the importance of using data in health care fraud investigations.

December 5, 5:00 PM ET:  Instant Challenge kicks off, winning team members each earn a $50 Amazon Gift Card.

December 12, 4:00 PM ET: Join a call with Lou Saccoccio, CEO of the National Health Care Anti-fraud Association (NHCAA), a private public partnership comprised of health insurance copay special investigative unit representatives and federal and state law enforcement and program integrity officers. Mr. Saccoccio will talk about health care fraud trends, and provide an overview of federal law as it relates to health care fraud.

Join Skype Meeting    passcode:    2292427#

or dial in at  (781) 271-2020 ## 2292427#

December 20, 5:00 PM ET: Competition closes. Use your analytics to develop an Investigation Recommendation Plan in the form of a presentation, as well as submit the algorithms used to develop the recommendation. Your plans should:

• Share your hypotheses: What fraud schemes, issues of concern, or provider types were prioritized in your analytics and why?
• Share your decision-making process: What influenced your decision to include certain features in your recommendations? Examples could be: amount of financial exposure, background research, known FWA issues, media reports, or a combination of factors.
• Share your analytics process: Describe your process for analytic tool(s) choice strengths of your algorithms and analyses.

Your entry which will include should be submitted following instruction on the Submissions page. You will submit an Investigation Recommendation Plan Saved as a PowerPoint file (.ppt), and Algorithms (any codes or worksheet that are used to produce the results). You may submit bibliographies, notes, and additional detailed information to support work in a separate Word document or in the notes section of PowerPoint, but judging will be based on PowerPoint slide content. Please name your files to include your Team name and University name. Instructions are available in the FAQs.

The (no more than 25-page) PowerPoint and submitted algorithms will be judged on technical competence, effective use of data to provide outcomes, creativity and innovation in detection approach, strength of the algorithms developed, use of tools, and the value of the information and insights obtained from the data. The top three scoring teams will be asked to present their plans to a panel of expert judges to be awarded the top prize.

February: The winner(s) are announced.

March: Top teams will be invited to MITRE’s McLean, VA offices to network with industry and government leaders and present their solutions.