The Centers for Medicare & Medicaid Services (CMS) reports in a news release that its analytics system has helped the agency identify and prevent $820 million in inappropriate Medicare payments in the system’s first 3 years of operation.
Called the Fraud Prevention System, the release explains that it was created in 2010 by the Small Business Jobs Act, and it helps to identify questionable billing patterns in real time and can review past patterns that may indicate fraud. Predictive analytics are used to identify troublesome billing patterns and outlier claims for action, similar to systems used by credit card companies.
Per the release, the system identified or prevented $454 million in payments in 2014 alone—a 10-to-1 return on investment. And over the last 5 years, the administration’s efforts have resulted in more than $25 billion returned to the Medicare Trust Fund.
“We are proving that in a modern healthcare system, you can both fight fraud and avoid creating hassles for the vast majority of physicians who simply want to get paid for services rendered. The key is data,” says CMS Acting Administrator Andy Slavitt, in the release.
In one case, the release explains, one of the system’s predictive models identified a questionable billing pattern at a provider for podiatry services that resulted in Medicare revoking the provider’s payments and referring the findings to law enforcement. The Fraud Prevention System also identified an ambulance provider for questionable trips allegedly made to a hospital.
During the 3 years prior to the system alerting officials, the provider was paid more than $1.5 million for transporting more than 4,500 beneficiaries. A review of medical records found significant instances of insufficient or lack of documentation. CMS also revoked the provider’s Medicare enrollment and referred the results to law enforcement, per the release.
“The third-year results of the Fraud Prevention System demonstrate our commitment to high-yield prevention activities, and our progress in moving beyond the ‘pay and chase’ model,” says Shantanu Agrawal, MD, CMS deputy administrator and director of the Center for Program Integrity, in the release.
“We have learned a lot in the 3 years since the Fraud Prevention System began, and as we learn, we continue to become more sophisticated in detecting aberrant billing patterns and developing leads for investigations and action,” he continues in the release.
In future years, CMS plans to expand the Fraud Prevention System and its algorithms to identify lower levels of noncompliant healthcare providers who would be better served by education or data-transparency interventions, the release explains.
[Source: Centers for Medicare and Medicaid Services]