CMS cutting-edge technology identifies and 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.
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 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.