Mathematics of outlier_detection_and_pattern_recognition_pharmacy_fraud_2013

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Pharmaceutical drug fraud a 360 degree hurt to US economy that also includes $60 Billion Medicare fraud and Money Laundry. They defeat the drivers of genomics, mHealth, TeleHealth innovations. Random samples are drawn from large samples and analyzed mathematically (calculus, Regression etc)

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Mathematics of outlier_detection_and_pattern_recognition_pharmacy_fraud_2013

  1. 1. Mathematics of Outlier Detection and Pattern Recognition: Pharmacy Fraud •Product: MED-DETECTION •Pharmaceutical drug non-adherence causes $290 Billion additional cost of care in USA. •Pharmaceutical drug reimbursements drive genomics innovation, care for chronic diseases and car accident patients, Central to mHealth and Tele-health initiatives. •Pharmaceutical drug fraud by patients, pharmacists and providers create 360 degree Economic Hurt that also includes $60 Billion Medicare Pharmacy Fraud and Money Laundry. •Complex Behavior: Mathematics Needed!
  2. 2. Sample 1: CMS Data Released in 2013: waves on right side (2010)
  3. 3. Sample 2: Mathematics extracted only 6% data as outlier: Pattern Continues…
  4. 4. Sample 3: 8 random samples were found from 450k data. All samples different in 2010.
  5. 5. Sample 4: Quantity dispensed to 360 units, Days supply to 180 days and Patient Payment to $570 in 450K data: note the right side in 2010, likely due lower DAYS_SUPLY_NUM.
  6. 6. Sample 5: Mathematical Equations were used for segmentation; note left (2008-2009) VS right (2010) data.
  7. 7. Sample 6: Patient paid_$ also decreased in right side of pane (2010) in all samples; plan looses $.
  8. 8. Sample 7: same pattern all over here; more intense in 2010.
  9. 9. Sample 8: 2008-2009 Learning the fraud and, 2010 Execution of fraud.
  10. 10. 2010 data separated from 2008-09 data and analyzed: Prescription drug fraud! The circle on right is very high quantity dispensed at low price… Why? Look at the hole in middle-why? Zero supply days for some money, nice!
  11. 11. CONCLUSIONS: REAL TIME ANALYTICS: STORE AND ANALYZE ONLY WHAT IS NEEDED. SHAVE COSTS OFF! • High- Low Fraud Condition: Low drug quantity sold for high price and high drug quantity sold at low price in order to stay below the radar. •It all adds up- 1000 times $10 per capsule is > than 50 times $100/ tablet. You make money from Fraud! •Similar pattern for Days_supply:- 30 days is more frequent than 90 days for the same price. Helps to make money more frequently from fraud. •Very few patients showed up for 60 Days_supply! Many of the same patients from 30 days showed up in 90 days supply to raise no suspicion….
  12. 12. TECHNICAL PRESENTATION OF NAVIN KUMAR SINHA, DOUBLE CHECK CONSULTING: 952-905-6636 (SINHANAVIN@HOTMAIL.COM). PUBLIC VIEW: AS WITH OTHER PRODUCTS OF DOUBLE CHECK CONSULTING (DATAVISIONS AND DATACONNECTIONS), THIS IS ALSO PUBLIC VIEW OF MED- DETECTION PRODUCT. THERE IS LOT MORE HERE BUT PUTTING 500 SLIDES IS INCONVENIENCE TO ALL. THANK YOU FOR YOUR TIME AND INTERESTS. MATHEMATICS IS BEAUTIFUL- CHEERS! Double Check Consulting

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