CMS fraud prevention attempts secure $42B

The Centers for Medicare and Medicaid Services (CMS) has accepted a multifaceted, proactive access to preventing deception, utilizing a heavy contribution in analytics and enforcement agency resources to secure $42 billion in fiscal years of 2013 and 2014.

CMS mentioned the significance of the savings in preventing deception or fraud in case to make sure the sustainability of the Medicare program and making definite the beneficiaries have future access to care.

In CMS’ yearly report to Congress on the effectiveness of the Recovery Audit Program—a method to combat fraud or deception, waste and abuse at a federal level—that was released previous week, the organization reported $24.8 billion of the $42 billion recovered came from prepayment consideration or review that hired advanced analytics.

By hiring this tactic to head off questionable payments in advance, instead of a “pay-and-chase” technique, program integrity contactors are capable to flag potential cases of deception or fraud through proactive data analysis before payments are created.

The Fraud Prevention System implements predictive algorithms and advanced analytics against the Medicare fee-for-service claims.

Contractors discovered 12.7% of Medicare fee for service claims in the FY 2014 were set at an inadequate payment rate, up from 10.1% in the FY 2013. When FPS predictive models recognizes egregious, suspect or aberrant activity, the system automatically produces and prioritizes leads for more review and inquiry, which are primarily utilized by Zone Program Integrity Contractors, in accordance to the report.

The system uses data sets from called-in tips, the Fraud Investigative Database, the Compromised Numbers Checklist and nationwide claims, among other sources, which are held in the Integrated Data Repository. Analysts use historical claims from the IDR to analyze patterns and develop models for the FPS, which in turn screens the aggregated information.

In the FY 2013, recovery auditors performed prepayment reviews on claims that historically outcome in high rates of inadequate payments, in accordance to the report. 7 states—California, Florida, Louisiana, Illinois, New York, Michigan and Texas—had high tragedies of fraud and inadequate payments, while 4 states—North Carolina, Missouri, Ohio and Pennsylvania—had huge claims volumes of short inpatient hospital stays.

Instead of the huge success with the program, CMS won’t systematically extend the predictive analytics technology beyond Medicare to all Medicaid and Children's Health Insurance Program claims; in the report, CMS points out that it isn’t cost effective for every state to embrace FPS.