CMS NEWS
FOR IMMEDIATE RELEASE
July 14,
2015
Contact: CMS Media Relations
(202) 690-6145 | CMS
Media Inquiries
CMS
cutting-edge technology identifies & prevents $820 million in improper
Medicare payments in first three years
The
Fraud Prevention System is one part of the administration’s effort to protect
the Medicare Trust Fund
After three years of operations,
the Centers for Medicare & Medicaid Services (CMS) today reported that the
agency’s advanced analytics system, called the Fraud Prevention System,
identified or prevented $820 million in inappropriate payments in the program’s
first three years. The Fraud Prevention System uses predictive analytics to
identify troublesome billing patterns and outlier claims for action, similar to
systems used by credit card companies. The Fraud Prevention System
identified or prevented $454 million in Calendar Year 2014 alone, a 10 to 1
return on investment.
"We are proving that in a
modern health care 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," said CMS Acting Administrator Andy Slavitt.
"Very few investments have a 10:1 return on taxpayer money."
The Fraud Prevention System was
created in 2010 by the Small Business Jobs Act, and CMS has extensively used
its tools, along with other new authorities made possible by the Affordable
Care Act, to help protect Medicare Trust Funds and prevent fraudulent payments.
For instance, last month Health & Human Services (HHS) and the Department
of Justice announced the largest coordinated fraud takedown in history,
resulting in charges against 243 individuals, including 46 doctors, nurses, and
other licensed medical professionals, for their alleged participation in
Medicare fraud schemes involving approximately $712 million in false
billings. Over the last five years, the administration’s efforts have
resulted in more
than $25 billion returned to the Medicare Trust
Fund.
The Fraud Prevention System helps to identify questionable billing
patterns in real time and can review past patterns that may indicate
fraud. In one case, 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 three
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.
“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,” said Dr. Shantanu Agrawal, CMS deputy
administrator and director of the Center for Program Integrity. “We have
learned a lot in the three 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.”
In future years, CMS plans to
expand the Fraud Prevention System and its algorithms to identify lower levels
of non-compliant health care providers who would be better served by education
or data transparency interventions.
For more information, please see
the Report under “Guidance and Reports” at: http://www.cms.gov/About-CMS/Components/CPI/Center-for-program-integrity.html
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