CMS Fraud Prevention Working

CMS Fraud Prevention Working

By Christopher Parrella J.D.

The days of “pay and chase” in the world of healthcare fraud are waning thanks to fraud prevention methods that the Centers for Medicare and Medicaid Services have put into place.

A newly released report from the Government Accountability Office (GAO) finds that Fraud Prevention System (FPS), which analyzes fee-for-service claims to identify healthcare providers with suspect billing patters is paying off.

CMS is the agency within the Department of Health and Human Services that administers the Medicare program and is responsible for making sure there is no fraud or waste.

In fiscal year 2016, for example, CMS reported that 90 providers had their payments suspended because of investigations initiated by FPS, resulting in an estimated $6.7 million in savings. In fact, 22 percent of Medicare fraud investigations were based on leads generated by the analysis of claims data.

FPS denies individual claims for payment that violate Medicare rules or policies through prepayment edits. These automated controls compare claims against Medicare requirements in order to approve or deny claims.

As of May, CMS implemented 24 of these prepayment edits, which resulted in the denial of nearly 340,000 claims, saving more than $20.4 million in fiscal year 2016.

Currently, fraud investigations are handled by program integrity contractors in seven zones (ZPICs). However, CMS is in the process of transitioning contracts from ZPIC to Unified Program Integrity Contractors (UPICs) that will combine responsibility for conducting program integrity activities for both Medicare and Medicaid and will be operated in five, instead of seven jurisdictions. That transition is expected to be completed by the end of this year.

Although FPS helps to speed up certain investigation processes, such as identifying and triaging

suspect providers for investigation, once an investigation is initiated, FPS has not sped up the process for investigating and gathering evidence against suspect providers, according to the report.

CMS, for its part, is putting into place a new information technology system that tracks such data and will be used to assess the programs effect on timeliness.

As we have written about before, predictive analytics is another powerful in anti-fraud efforts.

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