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North Carolina Fights Medicaid Fraud With Analytics

In two years, IBM data mining software has identified $191 million in potentially false Medicaid claims.

States budgets are under pressure, and Medicaid funding is often among the hardest hit. But in some states, including North Carolina, data analytics software is helping to uncover millions of dollars in potential savings through the detection of fraudulent Medicaid billing.

North Carolina's department of health and human services began collaborating with IBM in 2010 to develop analytics to help identify suspicious billing patterns by healthcare providers.

[Read how IBM helped South African insurer Santam fight fraud.]

To date, North Carolina has identified $191 million in potentially false Medicaid claims by 206 outpatient behavioral health providers in the state. North Carolina processes about 88 million claims totaling about $12 billion annually from 66,000 providers who treat the state's two million Medicaid patients.

Using the IBM software, the state has identified suspicious claims that include submissions from providers with patterns of billing that don't fit "the norm," said Al Delia, secretary of North Carolina's department of health and human services in a recent blog posting.

Read the rest of this article on InformationWeek

Nathan Golia is senior editor of Insurance & Technology. He joined the publication in 2010 as associate editor and covers all aspects of the nexus between insurance and information technology, including mobility, distribution, core systems, customer interaction, and risk ... View Full Bio

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