HealthCare Fraud Prevention Partnership NASA Challenge

HealthCare Fraud Prevention Partnership NASA Challenge

Jason Zeiler, CMSAndy LaMora

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• To exchange facts and information between the public and private sectors in order to detect and prevent health care fraud

• To enable members to individually share successful anti-fraud practices and effective methodologies and strategies for detecting and preventing health care fraud

• To focus on information sharing in two primary areas:1. Data analytics2. Outreach, education and information sharing

Healthcare Fraud Prevention Partnership (HFPP) Purpose

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Value Proposition

HFPP

Claims

Compromised Patient Data

Fraudulent Providers

Part

ner #

Z

Partner #Y

Enhanced

Fraud-

Fighting

Capabilities

Partner #X

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• The primary objective of the project involved building a data exchange network that would enable healthcare insurance-paying entities in both the public and private sector to safely and securely share information for purposes of detection and prevention of fraud, waste and abuse across partners.

Project Overview

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• Defining a data standard for exchanging healthcare claims data

• Defining a secure data exchange network• Identify and defining the roles of the Trusted Third

Party (TTP)• Providing documentation that drives adoption• Demonstration of the system with one or more proof

of concept applications

Principle Tasks

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• Solve problems (like developing code) by using a crowd of people: A Community– Open Source Communities: Apache, git, etc– Contributing Communities: wikipedia– Competition Communities: 541(G) Prize Firms

• What motivates a crowd to work?– “Guts, Glory, Gold”

• Contests can provide focus and spark to a crowd

Crowdsourcing

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• Total Registrations: 1406• Countries Represented: 52• Total Distinct Contributors: 107• Total Contests: 55

HFPP Community Stats

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• Projects are “atomized” to many contests• Contests are hyper-specific• … which lowers the need for domain experts• … while leaving the door open to them

How does it work?

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Atomization

MORE THAN 30+Specialized Contests thatallow for Hyper Specialization

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Atomization

Conceptualization

Specification

Wireframes

Storyboards

Architecture

Assembly

Component Dev

Bug Hunt

Bug Race

Idea Generation

Atomization – Why do it?

why

Probability

What are the Properties of the Big Contest?•Seeking in effect: brilliant, disciplined, proficient…

in one entity• = Rare!• = Hard to find• = Hard to price

And of an Atomized Challenge?

• = Hard to repeat • = Hard to scale

Find great ideas, from anyone

Let Designers Design

Let Builders Build

Atomizing by skill type = more contests• and thus opportunities to win• which increases participation• which increases contribution• which lowers risk• and increases quality• with shorter turn-around

Collaboration

• If you decompose from the start• AND assume different players at each step• You are forced to develop great info-sharing practices• -> Toolsets are key

Iteration

• Lots of “shots on goal”• Allows “early looks” and change cycles• And with a large enough community, lots of parallel work

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Putting it together at CMS

Open and Directed Innovation Contests• Idea Generation • Conceptualization

Creative Contests• Logo• Wireframes• Storyboards• Mobile Screen

Software Contests• Software

Specification• System Architecture• Module Architecture• Component Design• Component

Development• User Interface

Prototype• Assembly• Test Scenarios• Test Suites• Bug Hunts• Content Creation

Credit: Chip Garner and Anne Wood, CMCS/CHIP

Execute

Self CorrectForge Ahead

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• Back to CMS…

Thanks!

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• Tangible products and code that can be implemented into the TTP system

• Many ideas and different points of view and solutions to the issue at hand or overall reason for using a challenge

• Challenges can be an option and a good replacement to traditional acquisition (less money, time, different approaches, input and solutions), depending on the project

• The challenge process can also be used to give valuable input to the traditional acquisition process by adding or filling in gaps in information that may not have been identified initially (helping complete the SOW and a better end result)

Challenge Benefits