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Medicare Expands Analytic Tools To Fight Fraud

The Centers for Medicare and Medicaid Services will use predictive modeling to identify fraudulent billings before they are paid.

Nicole Lewis

December 17, 2010

2 Min Read

CMS and many companies in the private sector have been testing and using predictive modeling programs to help identify possible fraudulent providers and scams, based on historical information about the individual or the company in which the individual is affiliated.

In one pilot program, CMS partnered with the Federal Recovery Accountability and Transparency Board (RATB) to investigate a group of high-risk providers. By linking public data (information found by anyone on the Internet) with other information, like fraud alerts from other payers and existing court records, a sophisticated, potentially fraudulent scheme was uncovered.

The scheme involved opening multiple companies at the same location on the same day using provider numbers of physicians in other states. The data confirmed several suspect providers who were already under investigation and, through linkage analysis, identified affiliated providers who are now also under investigation.

According to HHS, the Affordable Care Act provides additional tools and resources to fight fraud in the healthcare system by allocating an additional $350 million over the next 10 years through the Health Care Fraud and Abuse Control Account.

The act toughens sentencing for criminal activity, enhances screenings and enrollment requirements, encourages increased sharing of data across government, expands overpayment recovery efforts, and provides greater oversight of private insurance abuses.

Recent efforts by HHS and the Department of Justice to fight Medicare and Medicaid fraud are paying off. In FY 2009, anti-fraud efforts put $2.51 billion back in the Medicare Trust Fund, resulting from civil and administrative recoveries, as well as fines in criminal matters. This was a $569 million, or 29%, increase over FY 2008. In FY 2009, more than $441 million in federal Medicaid money was returned to the Treasury, a 28% increase from FY 2008.

Most recently, in FY 2010, the Department of Justice obtained settlements and judgments of more than $2.5 billion in False Claims Act matters alleging healthcare fraud. This is more than ever before obtained in a single year, up from $1.68 billion in FY2009.


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