An analytics system established three years ago by the Centers for Medicare & Medicaid Services has identified or prevented $820 million in inappropriate payments, according to a CMS news release.
The system, dubbed the “Fraud Prevention System” uses predictive analytics to find questionable billing patterns and claims. A similar system is used by credit care companies, according to the news release. Created in 2010 by the Small Business Jobs Act, the Fraud Prevention System has become an important tool for CMS in its efforts to preserve the Medicare Trust Funds and stop fraud, the news release said. The Affordable Care act also has played a role in allowing the creation of the Fraud Prevention System, according to the news release.
In addition to identifying suspicious patterns in real time, the system also reviews past patterns that may show signs of fraudulence, the news release said. Among cases of fraud the system has uncovered was a problematic billing patterns involving a podiatry provider, with the case ending up being referred to law enforcement, the news release said. Another case involved suspicious trips by an ambulance provider who in three years before the system was in place, was paid more than $1.5 million for transporting more than 4,500 beneficiaries. An investigation revealed major inefficiencies or insufficient lack of documentation, the release said, and the provider’s Medicare enrollment was revoked. The results of that investigation also were referred to law enforcement.
In a 2012 report to Congress, CMS said it had implemented the system nationwide to better coordinate fraud-fighting efforts across program integrity contractors’ jurisdictions. CMS also saved $3 for every $1 spent on the system, the report said. Within the first year, the system prevented or identified an estimated $115.4 million in payments, CMS told Congress. CMS also highlighted its modern, 21st century approach to tracking fraud, which includes the creation of twin pillars to address fraud nationally on multiple levels. The Fraud Prevention System is one of those pillars, according to CMS, with an Automated Provider Screening System serving as the other pillar. The screening system identifies ineligible providers prior to their enrollment or revalidation, the report said. It also allows CMS to systematically screen providers against thousands of data sources, including licensing and criminal records, CMS told Congress in the report.
“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,” CMS Acting Administrator Andy Slavitt said in the news release. ”Very few investments have a 10:1 return on taxpayer money.”
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