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.

 

Alert: An Important EHR Incentive Program Deadline is Approaching

November 30 is the Last Day for Eligible Hospitals and Critical Access Hospitals (CAHs) to Register and Attest for an Incentive Payment for FY 2011

Eligible hospitals and CAHs have 60 days after the end of the fiscal year to submit their attestation for the Medicare Electronic Health Record (EHR) Incentive Program. The last day that eligible hospitals and CAHs can register and attest for fiscal year (FY) 2011 is November 30, 2011. For eligible hospitals and CAHs, this means that they must successfully register and then attest to demonstrating meaningful use by this date in order to receive an incentive payment for FY 2011.

Note, in order to attest, you must have begun your 90-day reporting period on or before July 3, 2011. Registration will be open after November 30th for eligible hospitals and CAHs who wish to register for a 2012 payment.

CMS encourages eligible hospitals and CAHs not to miss the deadline to attest for an incentive payment for FY 2011.

Registration Resources

To help eligible hospitals and CAHs with registration, CMS has created a Registration User Guide for Eligible Hospitals and CAHs. Additionally, eligible hospitals and CAHs can view the Medicare and Medicaid EHR Incentive Programs Webinar for Eligible Hospitals and CAHs, which walks hospitals through the registration process.

Attestation Resources

CMS has a number of tools available to help eligible hospitals and CAHs prepare for attestation. They can use the CMS Eligible Hospital and CAH Attestation Worksheet to record their meaningful use measures and then use as a reference when attesting for the Medicare EHR Incentive Program in CMS' web-based Registration and Attestation System. The Meaningful Use Attestation Calculator and Attestation User Guide for Eligible Hospitals and CAHscan also help with the attestation process.

Looking Ahead

Take a look at all of the other EHR Incentive Program important dates that are coming up by going to our CMS Medicare and Medicaid EHR Incentive Programs Milestone Timeline, or reviewing the “Important Dates” section of the EHR Incentive Programs’ Overview page.

Want more information about the EHR Incentive Programs?

Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

July 3rd marks an important deadline for eligible hospitals and critical access hospitals (CAHs).

The last day that eligible hospitals and CAHs can begin their 90-day reporting period in Fiscal Year (FY) 2011 for the Medicare EHR Incentive Program is July 3, 2011. For hospitals, this means that they must begin their consecutive 90-day reporting period by July 3rd if they still want to successfully demonstrate meaningful use and receive an incentive payment for FY 2011.

Resources to Help

CMS has developed some tools to help providers attest. Eligible hospitals and CAHs who have completed their reporting period can use the CMS Eligible Hospital and CAH Attestation Worksheet to log their meaningful use measures to use as a reference when attesting for the Medicare EHR Incentive Program in the CMS system.

Additionally, the Meaningful Use Attestation Calculator allows eligible hospitals and CAHs to test whether or not they will successfully demonstrate meaningful use for the EHR Incentive Programs and the Attestation User Guide for Eligible Hospitals will walk eligible hospitals and CAHs through the attestation system, helping them to successfully attest to meeting meaningful use.

Looking Ahead

September 30, 2011 is the last day of the federal fiscal year, marking the end of the reporting year for eligible hospitals and CAHs. See what other important dates are coming in 2011 by going to our CMS Medicare and Medicaid EHR Incentive Programs Milestone Timeline, or reviewing the “Important Dates” section of the EHR Incentive Programs’ Overview page.

Want more information about the EHR Incentive Programs? 

Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.