1 The MITRE Corporation Center for Transforming Health

|1| The MITRE Corporation, Center for Transforming Health: Community-Based Innovation to Combat Fraud The Healthcare Anti-Fraud Academic Competition © 2019 The MITRE Corporation. All rights reserved. Approved for Public Release; Distribution Unlimited. # 19 -3251.

2 Welcome Teams! Today’s Objectives: § Introduce competition concepts and expectations § Overview resources and materials § Submissions requirements § Judging process © 2019 The MITRE Corporation. All rights reserved. Approved for Public Release: PRS Release Number: 19 -3251

3 The Healthcare Anti-Fraud Academic Competition Healthcare fraud, waste, and abuse costs the U. S. over $100 M every day and places the health and welfare of all individuals at risk. 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 solution 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. © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

4 The Problem: The New Fraud Fighting Workforce Needs Multiple Advanced Skills and Lacks a Recruitment Pipeline Skills Needed • • • Big data manipulation and analytics Predictive modeling Visualizations Clinical expertise Investigative savvy Pipeline Deficiencies • • Analytic skill shortage Limited exposure to fraud focus Lack of datasets to test skill, innovation Knowledge of industry players © 2019 The MITRE Corporation. All rights reserved. Approved for Public Release: PRS Release Number: 19 -3251.

5 The MITRE Team Project Leads Lisa Cannady Song Chen Communications & Recruitment Erin Carlson Ryan Kuo Analytics Song Chen Will Lee Lisa Cannady Anuj Misra Amber Fee Judging Alanna Lavelle © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

6 Important Dates • Nov 4, 2019 Competition Opens, data is available for download • Nov 7, 2019 Kick-off meeting 4: 00 – 5: 00 p. m. EST • Nov 14, 2019 Data Office Hours 4: 00 p. m. EST • Nov 21, 2019 Industry Expert Presentation • Dec 5, 2019 Industry Expert Presentation • Dec 20, 2019 Entry submission to portal by 5: 00 EDT • Jan 23, 2020 Announcement of Finalists • Mar 12, 2020 MITRE Day event/Announce Winning Team © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

7 Competition Structure Explain Decisions MITRE PROVIDES • • • Synthetic Data Set References Presentations Online resources Portal for communication Visit portal to download dataset Construct Investigation Plan Recommendations Prioritize Findings Identified Outliers Submit to MITRE for Scoring Perform analytics & research Finalists named Select your Analytic Tools © 2019 The MITRE Corporation. All rights reserved. Approved for Public Release: PRS Release Number: 19 -3251.

8 Competition Portal © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

9 Data to Drive Decisions Basic Anatomy of a Health Care Fraud Investigation I. Detection • Internal reactive, internal proactive, external sources II. Assessment • Establish predication or need for continued investigation III. Investigative Strategy • Case prioritization and action plans IV. Case Investigation • Gather the facts V. Report Writing • Basis for action IV. Determination of Action and Final Resolution © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

10 You are the Data Analytics Team Data analytics is the critical first step in the fight against fraud, waste, and abuse. • Per the NHCAA, 60 -90% of all investigations start with data • Identify anomalies and patterns of suspicious behavior that may otherwise go undetected • Shape investigation priorities to ensure resources are focused on areas of highest risk • Influence policy and processes to strengthen program integrity Your Competition Goal: Use your analytics to detect anomalies, prioritize findings, and develop an Investigation Recommendation Plan for submission. . Approved for Public Release: PRS Release Number: 19 -3251

11 Competition Data • One Claims dataset • Outpatient claims • With emphasis on urine drug tests • From 2014 to 2018 • Synthetic dataset based on Synthea. TM • Synthea is an open source software to create synthetic patients' medical history • Used outputs from Synthea to create base claims dataset • Inserted more than 30 different fraud patterns and scenarios • Dataset Descriptions • 100 k patients, 70 k providers • 5 million records rows, 2 million claims • 2 GB in data size © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

12 Important Reminders • This dataset is created based on Synthea, a synthetic program for patient medical histories. • We inserted genetic fraud scenarios, but please focus on urine drug tests related fraud schemes. • Urine drug tests have been several related fraud schemes • Do NOT attempt to re-identify information as this information are all random matched and all medical services are not real. • All the addresses could be real, but please do not try to match any real medical facilities to these addresses. • For any data related questions, please email hcfchallenge@mitre. org. © 2019 The MITRE Corporation. All rights reserved. Approved for Public Release: PRS Release Number: 19 -3251

13 About Urine Drug Test Screening Urine Drug Screening (UDS) is used as a method to ensure that prescribed medications are being taken appropriately and that illicit drugs are not being used. Drug screening is performed to detect the presence or absence of a specific drug or drugs in the body. A physician may request a urine drug screen to determine if a person has a toxic level of a prescribed drug or if a person has been misusing opioids or other illicit substances. Urine drug screens can be used to detect such substances as: • Alcohol • Marijuana • Amphetamines • Methamphetamine • Barbiturates • Opioids • Benzodiazepines • Cocaine © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

14 Types of Urine Drug Screen Tests • Presumptive/Qualitative • These tests determine the presence or absence of a drug or drug class and results are stated as positive or negative. • Only one presumptive code can be reported per day per patient, regardless of the number of drugs or drug classes being tested. • Definitive/Quantitative • These tests determine the presence of a specific drug and the quantity of the drug in the body. • A definitive code can only be reported once per day per patient. Regardless of the number of drugs or drug classes being tested. Guidelines: • Multiple providers should not bill urine drug tests on the same day. • A definitive test can be performed without a presumptive but is not expected to be the norm. • Definitive tests are reimbursed at a higher rate than presumptive tests. © 2019 The MITRE Corporation. All rights reserved. . . Approved for Public Release: PRS Release Number: 19 -3251

15 UDS codes within the Dataset Code URT 0477 Description Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg immunoassay) read by instrument-assisted direct optical observation, includes sample validation URT 0478 Drug tests(s), presumptive, any number of drug classes; any number of devices or procedures, (eg immunoassay) read by instrument-assisted direct optical observation, includes sample validation URT 0479 URT 0480 URT 0481 URT 0482 URT 0483 Drug test definitive 1 -7 classes Drug test definitive 8 -14 classes Drug test definitive 15 -21 classes Drug test def 22+ classes * Note there are 33 qualitative or presumptive codes and 4 definitive or quantitative test codes. © 2019 The MITRE Corporation. All rights reserved. Approved for Public Release: PRS Release Number: 19 -3251

16 Data Elements Column Name claim_id start_date stop_date proc_cd proc_desc paid_amt visit_code visit_class diagnosis_code diagnosis_description prov_id prov_specialty pat_id birthdate patient_gender referring_prov_id referring_prov_name Column Description Claim identifier Start of service date End of service date Procedure Code Procedure code description Payment amount Place of Service or Visit Code description Diagnosis code description Provider identifier Provider specialties Patient identifier Patient date of birth Patient gender Referral provider identifier Referral provider name © 2019 The MITRE Corporation. All rights reserved. . . Approved for Public Release: PRS Release Number: 19 -3251

Data Evaluation Successful detection of outlier providers Registered Contestants Successful identification of underlying schemes Successful implementation of innovative algorithms and their performance © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

18 Developing an Investigative Recommendation Plan Your goal is to 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 and the strengths of your algorithms and analyses. © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

19 Investigation Recommendation Plan 1) What fraud schemes and provider types did you test? • Describe where you successfully found outliers and schemes • Evaluate the scope of the schemes by their frequency and impacts. 2) What outlier should be the #1 priority to pursue for investigation? • How did you prioritize your recommendations and why? • What influenced your decision to select the #1 priority? • Examples could be amount of financial exposure, background research, known FWA issues, media reports, or a combination of factors. 5) What analytic techniques were developed and used? • Describe the specific techniques used such as utilization-based metrics, geospatial analysis, time-based pattern analysis, and community-based analysis • Include information regarding the strengths of your algorithms and analyses and if there any factors that should be further explored. (Examples: efficiency of targeting and degree of complexity) © 2019 The MITRE Corporation. All rights reserved. Approved for Public Release: PRS Release Number: 19 -3251.

20 Submission Format • Power. Point format • Maximum 25 slides • Name files using team name • Submit two files: • Investigation Recommendation Plan Saved as a normal power point file (. ppt) • Algorithms (any codes or worksheet that are used to produce the results) • Bibliographies, notes, and additional detailed information to support work may be submitted in a separate Word document or in the notes section of Power. Point, but judging will be based on Power. Point slide content. • Submission deadline: 5: 00 p. m. EDT December 20 © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

21 Judging Criteria • Written presentations will be evaluated against four scored categories: • Technical Competence [Weight 20%] • Data Use for Effective Outcomes [Weight 20%] • Innovation in Analytics Approach [Weight 30%] • Insights Regarding Data Value [Weight 30%] • MITRE will award a score to each submission based on the published score sheet criteria. 0= Information not provided 1= Skill not adequately demonstrated 2= Skill mostly demonstrated 3= Skill demonstrated 4= Exceptional skill demonstrated • Two-level judging process: • Initial screening by MITRE FWA experts • Second assessment by government and industry experts © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

22 Technical Competence 20% Did the presentation address the primary goal of using analytics to identify potential FWA in the data? Did the team demonstrate creative use of analytic tools and demonstrate innovative technique? Did the team show evidence of practical and useful techniques in prioritizing analytic findings? Did the teams attempt to identify multiple instances/types of FWA? Did the presentation adequately convey the findings and recommendations? Category Total © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

23 Effective Outcomes and Technical Competence Did the presentation provide evidence of the identification of aberrant behaviors and trends? For the priority scheme/scenario presented: Did the evidence presented support the allegation? Did the data, as presented, provide actionable evidence regarding the allegation? Was the method of data presentation innovative or creative? Category Total © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251 20%

24 Innovation in Analytics Approach 30% Were analytic tools and innovative techniques used to derive recommendations? Were innovative and creative analytic designs or approaches used that significantly aided in the identification of potential FWA schemes? Did the team employ more than one analytic approach to uncover their prioritized scheme? Were the schemes uncovered complex and required advanced analytic approaches? Did the team build new algorithms or employ a novel use of existing methods? Was the team’s approach replicable, and able to be applied, with impact, in other scenarios? Category Total © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

25 Insights Regarding Data Value 30% Did the presentation demonstrate how data may be used to inform decision-making and prioritization of resources in the fight against FWA? Did the presentation provide useful information in the analysis regarding key factors impacting prioritization? Were the following factors addressed: Scheme Complexity: Did the case involve several types or levels of potential FWA? Did the described fraud involve multiple providers, locations, or specialties? Were there shared beneficiaries or other indicators of complexity? Financial Impact: Did the top selected scheme have a significant exposure amount (ex. more than $1 million paid exposure)? Patient Harm Potential: Could the identified schemes include compromised medical records/identities or directly impact to patient’s health? Potential for Collaboration: Did the team identify the potential for impact to others by these behaviors? Category Total © 2019 The MITRE Corporation. All rights reserved. Approved for Public Release: PRS Release Number: 19 -3251.

26 Two Tier Judging Process 1) Initial screening by MITRE Team • MITRE Lead Judge • Accredited Healthcare Fraud Investigators (AHFIs) • Experienced Health Fraud Data Analysts The top 5 scoring submissions will be submitted to the expert judging panel for review and winner selection. 2) Expert Judging Panel • MITRE Lead Judge • Special Investigation Unit Directors and Senior Management © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

Competition Awards • MITRE Day – March 12, 2020 • Opportunity for teams to meet virtually with a mix of government sponsors and private industry to present their solutions • Winner will be announced, finalists recognized • Press release, Twitter, Facebook, Linked IN • Press kit provided to Universities © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

Contact Information mitre. org/healthcare-anti-fraud Access Help Email: hcfchallenge@mitre. org Emergencies: Erin - 410 -322 -9664 © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251

| 29 | MITRE’s mission-driven teams are dedicated to solving problems for a safer world. Through our federally funded R&D centers and public-private partnerships, we work across government to tackle challenges to the safety, stability, and well-being of our nation. Learn more www. mitre. org © 2019 The MITRE Corporation. All rights reserved. . Approved for Public Release: PRS Release Number: 19 -3251