Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Chapter 19

Components of the Data Mapping and Data Mining Process

Falsehood is easy, truth so difficult.

–George Eliot

Truth is always difficult; falsehood is so easy to bury in healthcare. Otherwise, we would not have the opportunity to fund a $24-million-per-hour industry dedicated to waste, fraud, and abuse. Blending the science of data mapping and data mining is critical toward developing a warehouse used to derive intelligence; without these tools, it is almost impossible for those hunting for healthcare fraud to put a dent into the amount of money that is lost by the hour. Data mapping is discussed in Chapter 17 as a separate skill set because it is often overlooked or not well thought out. Data mining is then discussed in Chapter 18. The two concepts are developed independently of each other; however, a contemporaneous component does exist.

Consider the data mapping and mining process a long road trip. First is the decision to make the road trip, the events that will be part of it, and the anticipation of final destination. Second, we need the appropriate automobile. This cannot be determined until after we know how many passengers (healthcare continuum players) are to be transported. We need a (data) map to route our trip. However, multiple routes exist; therefore we review relevant facts (mine) to identify which route would be most conducive in achieving or adjusting our objective. We need to be prepared for variations (anomalies) on the travel route that do not appear ...