Pandemic profiteering at a time of crisis: Using python to detect fraud in covid-19 testing and treatment payments

Abstract

During the pandemic, the Centre for Medicare and Medicaid Services (CMS) introduced blanket waivers and rule flexibilities to address rising COVID-19 cases. This included expanding telehealth services to urban areas and waiving certain reporting requirements, along with various testing options such as surveillance testing, school and workplace testing, self-tests, and testing in more inpatient settings such as nursing homes. The federal and state governments also covered COVID-19 testing, vaccination and treatment for the uninsured population, creating opportunities for fraud and unnecessary testing, double billing, kickbacks, and deceased billing, mainly for monetary gain, by unscrupulous healthcare providers. Using Python programming, the study adopted an unsupervised learning approach by employing Isolation Forest to detect healthcare providers who were anomalies in the payment for COVID-19, treatment and vaccination by the Health Resources and Services Administration (HRSA). Additionally, using official search enquiry into official U.S. government websites such as the FBI, USDOJ, and HHS-OIG, this study identified eight (8) fraud, waste and abuse schemes related to laboratory testing and treatment. The isolation forest algorithm, set at a 5% contamination level, identified 1,890 healthcare providers (7.64% of total claims) as being anomalies. These results support the recommendations given to the HRSA by the Office of Inspector General of the Department of Health and Human Services (HHS-OIG), emphasizing the need for identifying and addressing improper payments. Protecting public health resources requires preventing fraud in the healthcare industry. Strong education programs for healthcare workers are crucial, as are vigilant oversight and collaboration between federal and state agencies. Additionally, this study emphasizes how crucial it is to use official government resources—such as the FBI, HHS-OIG, USDOJ, and CDC—to efficiently detect and prevent fraudulent activities. In the wake of information asymmetry, calls for private‒public partnerships are needed to address fraud, waste and abuse in the healthcare industry.