Electronic fraud detection in the U.S. Medicaid Healthcare Program: lessons learned from other industries

It is estimated that between $600 and$850 billion annually is lost to fraud, waste, and abuse in the US healthcare system,with $125 to$175 billion of this due to fraudulent activity (Kelley 2009). Medicaid, a state-run, federally-matchedgovernment program which accounts for roughly one-quarter of all healthcare expenses in the US, has been particularlysusceptible targets for fraud in recent years. With escalating overall healthcare costs, payers, especially government-runprograms, must seek savings throughout the system to maintain reasonable quality of care standards. As such, the need foreffective fraud detection and prevention is critical. Electronic fraud detection systems are widely used in the insurance,telecommunications, and financial sectors. What lessons can be learned from these efforts and applied to improve frauddetection in the Medicaid health care program? In this paper, we conduct a systematic literature study to analyze theapplicability of existing electronic fraud detection techniques in similar industries to the US Medicaid program

Bridging the gap between research and agile practice: an evolutionary model

There is wide acceptance in the software engineering field that industry and research can gain significantly from each other and there have been several initiatives to encourage collaboration between the two. However there are some often-quoted challenges in this kind of collaboration. For example, that the timescales of research and practice are incompatible, that research is not seen as relevant for practice, and that research demands a different kind of rigour than practice supports. These are complex challenges that are not always easy to overcome. Since the beginning of 2013 we have been using an approach designed to address some of these challenges and to bridge the gap between research and practice, specifically in the agile software development arena. So far we have collaborated successfully with three partners and have investigated three practitioner-driven challenges with agile. The model of collaboration that we adopted has evolved with the lessons learned in the first two collaborations and been modified for the third. In this paper we introduce the collaboration model, discuss how it addresses the collaboration challenges between research and practice and how it has evolved, and describe the lessons learned from our experience

Scaling Success: Lessons from Adaptation Pilots in the Rainfed Regions of India

"Scaling Success" examines how agricultural communities are adapting to the challenges posed by climate change through the lens of India's rainfed agriculture regions. Rainfed agriculture currently occupies 58 percent of India's cultivated land and accounts for up to 40 percent of its total food production. However, these regions face potential production losses of more than $200 billion USD in rice, wheat, and maize by 2050 due to the effects of climate change. Unless action is taken soon at a large scale, farmers will see sharp decreases in revenue and yields.Rainfed regions across the globe have been an important focus for the first generation of adaptation projects, but to date, few have achieved a scale that can be truly transformational. Drawing on lessons learnt from 21 case studies of rainfed agriculture interventions, the report provides guidance on how to design, fund and support adaptation projects that can achieve scale

Putting Community First: A Promising Approach to Federal Collaboration for Environmental Improvement: An Evaluation of the Community Action for a Renewed Environment (CARE) Demonstration Program

This report is an independent evaluation of the Environmental Protection Agency's (EPA) Community Action for a Renewed Environment (CARE) Demonstration Program, a community-driven process that uses the best available data to help communities set priorities and take action on their greatest environmental risks. CARE fosters local partnerships that seek participation from business, government, organizations, residents and EPA staff. It also supports a public, transparent planning and implementation process based on collaborative decision-making and shared action.Key FindingsThe National Academy Panel overseeing this effort was impressed by the dedication of the EPA staff to this unique initiative and commended the EPA for its efforts to partner with communities in achieving important long-term and sustainable environmental improvements at the local level. Recommended actions for the CARE Program include: (1) develop and implement a multifaceted information sharing approach; (2) coordinate and refine internal program management activities; and (3) develop a strategic plan and a business plan for CARE

Outcome evaluation of research for development work conducted in Ghana and Sri Lanka under the Resource, Recovery and Reuse (RRR) subprogram of the CGIAR Research Program on Water, Land and Ecosystems (WLE).

This is the main report of an external evaluation of the Resource Recovery and Reuse Flagship of the Water Land and Ecosystems (WLE) CGIAR Research Program. WLE commissioned the study. The Evaluators interviewed researchers and partners in two countries, Ghana and Sri Lanka, and in Ghana visited two sites. They also interviewed key international partners and analyzed a wide range of documents, reports and publications. The evaluation was focused on understanding how and in what ways the research and other activities carried out by IWMI and supported by WLE contributed to the outcomes. In essence, the purpose was to understand the specific impact pathways from research to outputs and outcomes

Towards guidelines for building a business case and gathering evidence of software reference architectures in industry

Background: Software reference architectures are becoming widely adopted by organizations that need to support the design and maintenance of software applications of a shared domain. For organizations that plan to adopt this architecture-centric approach, it becomes fundamental to know the return on investment and to understand how software reference architectures are designed, maintained, and used. Unfortunately, there is little evidence-based support to help organizations with these challenges. Methods: We have conducted action research in an industry-academia collaboration between the GESSI research group and everis, a multinational IT consulting firm based in Spain. Results: The results from such collaboration are being packaged in order to create guidelines that could be used in similar contexts as the one of everis. The main result of this paper is the construction of empirically-grounded guidelines that support organizations to decide on the adoption of software reference architectures and to gather evidence to improve RA-related practices. Conclusions: The created guidelines could be used by other organizations outside of our industry-academia collaboration. With this goal in mind, we describe the guidelines in detail for their use.Peer ReviewedPostprint (published version

Process Evaluation Insights on Program Implementation

This white paper has the explicit intention to draw lessons learned from the past 30 years of energy efficiency program evaluation in order to facilitate improved program design and implementation going forward. The discussion in this white paper is developed based on interviews with 43 individuals who are either practitioners or users of process and market evaluation. In addition, we obtained references to published materials from our contacts and reviewed conference proceedings dating from 1992 to 2008, which resulted in a review of nearly 100 articles or reports documenting the results of, or commenting on, process and market evaluations

Agile in Public Administration: Oxymoron or reality? An experience report

In the last 10 years, Agile methods and practices have emerged as an alternative for software development. Different "flavors" of Agile have appeared ranging from project management to tests organization. These approaches have being gaining popularity and involve now a solid option for organizations developing software, but what about Public Administrations? Is Agile a suitable option for developing software in Public Administrations? Even if Public Administrations have been traditionally regarded as changeresistant, Agile approach can also provide them with the benefits of quick adaptation and frequent value delivery. This paper presents the results of two different projects, which use an Agile framework based on Scrum, developed by a Spanish Public Administration. Additionally, after considering the obtained results, it takes out some relevant learned lessons on the suitability of applying Agile approaches to Public Administration environments.Ministerio de Ciencia e Innovación TIN2010-20057-C03-02Junta de Andalucía TIC-578