SAS, Healthcare & Government Fraud Specialist
John is a subject matter expert (SME) in health care and government, part of the SAS Global Fraud & Security Intelligence practice. John is the former Program Integrity Director for Ohio Medicaid, the 5th largest state Medicaid agency in the U.S. with 3 million covered lives and now $29B budget. During his tenure there, Ohio was a national leader in health care fraud indictments and convictions. The collaborative efforts of Ohio Medicaid with the Ohio Auditor of State and the Ohio Attorney General’s Medicaid Fraud Control Unit (MFCU) earned this group honors from the Harvard University’s Ash Center for Democratic Governance and Innovation.
John has a BA in Accounting, and he is a Certified Public Accountant (CPA), Certified Fraud Examiner (CFE) and plans to earn the Accredited Healthcare Fraud Investigator (AHFI) certification. John has spoken at state and national training conferences and taught at the national CMS Medicaid Integrity Institute. He is a former retail pharmacy technician and began his government health care career at the Ohio State University Wexner Medical Center and James Cancer Hospital Solove Research Institute.
The health care industry is undergoing digital transformation, like all other industries, and SAS support on digital transformation also helps us adapt with health care fraud solutions. The COVID-19 pandemic is accelerating this transformation, and it has changed service delivery forever. While younger consumers were already demanding more integration of technology and easier access to care and health management, COVID-19 forced many providers and seniors into adoption. This means integrating technology like artificial intelligence (AI), Internet of Things (IoT) devices, telehealth, and wearables along with those evolving payment models like value-based care and Whole Person Care.
Health care fraud is adapting as well, using technology itself, and continually looking to exploit weaknesses in both advancing technologies and the people who use them. Ransomware attacks and data breaches are just two examples, but both lead to identity theft and back to traditional health care fraud schemes. Therefore, as the industry will be more focused on data security, cloud deployment, and streaming data analytics. Fraud, waste, and abuse solutions must align to these broader strategic goals and how analytics solutions are managed across the business by augmenting human efforts with tools like computer vision, document vision, robotic process automation (RPA), and intelligent decisioning that promote efficiency.
SAS is driven by curiosity and innovation. We’ve used AI since our inception and are investing $1B over 3 years to advance AI technologies. We’re a privately held advanced analytics company that focuses on broad business solutions. SAS is supporting digital transformation in government and major businesses around the globe. Innovation draws from interdisciplinary work with techniques like design thinking. We have a health care focus, but we draw upon on knowledge from other industries. For example, as industry controls improved in financial services, fraudsters took what they learned there and moved into the health care fraud arena. We continually evolve our advanced analytic solutions to stop them.
SAS works with federal and state government, commercial payers, and pharmacy benefit management. A broad perspective helps us see the forest rather than just the trees. Our FWA solutions are flexible by design because the health care system and fraud are continually changing. SAS supports technology change in the health care delivery system (services, med-tech, and pharma), payment and FWA. Therefore, SAS is at the forefront of industry changes and our SMEs use this knowledge to adapt our advanced analytics to stay ahead of fraudsters and to better support FWA fighters.
The value SAS provides is driven by our own values; we are: Curious, Passionate, Authentic, and Accountable. Our mission is to empower and inspire with the most trusted analytics. Again, these collectively drive innovation in all SAS does.
Our greatest value to our FWA community is the desire to help customers achieve their goals. This is especially true with health care where the enormous financial costs of FWA are only exceeded by the human costs FWA can inflict. At SAS, we never forget that health care is about people and making their lives better and longer. The FWA community knows fraud puts patients at risk.
SAS was named a Fast Company 2020 Innovative Team of the Year for its health care fraud fighting partnership with Prime Therapeutics. In 2021, SAS was also ranked a Best Workplace for Innovators by Fast Company for the second year in a row. SAS continually innovates to deliver world-class FWA analytics to our community of health care fraud fighters. SAS is also at the forefront of related technologies like computer vision, text analytics, etc. and uses these to deliver solutions to help our FWA community do more with limited resources.
SAS is passionate about people and using advanced analytics to make their lives better. This starts with our founder, Dr. Jim Goodnight. It’s why SAS has been a named a Great Place to Work® for over 20 years, and SAS is rated a best workplace in countries around the world. We were recently named on People’s 50 Companies That Care list. Therefore, it is not surprising patient safety is a core value of health care fraud SMEs, or that SAS has #data4good efforts around the world. Dr. Goodnight also believes that the best work environment allows employees to do their best work, and he is right.
The Aite Group recently named SAS as Best in Class for health care payment integrity:
“Health care payers are on a quest to make informed decisions as they strive to optimize their claims processing and payment operations. Payment integrity tools play an important role in these optimization initiatives,” said Inci Kaya, Senior Analyst of Aite Group’s Health Insurance practice. “SAS excels in features and functionality, enhanced by an intuitive user interface, ease of implementation and integration, and its customization support.”
Like NHCAA members, SAS is passionate about fighting FWA and it shows.