CMS has taken their fight against health care fraud to a new level, announcing the start of a partnership with companies that provide predictive modeling to anticipate and prevent potentially wasteful, abusive or fraudulent payments before they occur.
Soon, every Medicare claim will be subject to a computerized analysis that reveals all claims paid to that provider. By tracking billing patterns and other statistical information, real-time aberrant trends can be spotted that will alert CMS to locating fraudulent providers before they begin receiving Medicare funds.
Predictive modeling tools are already used by banks and credit card companies to identify potential fraud before it occurs. CMS has used the tool in pilot projects, and has used those results to begin administrative actions against "false fronts" in several states.
Historically, CMS relied on the "pay and chase" method to track down potential violators and then tried to recover the funds. In 2010, the Department of Justice obtained settlements and judgements of more than $2.5 billion in False Claims Act matters alleging health care fraud. Thanks to funding from a portion of the Affordable Care Act, CMS will be purchasing new tools and resources to track provider specific trends and quickly catch anyone attempting to steal taxpayer dollars.
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Starting July 1, CMS will use this technology to analyze claims. For the first time, CMS will have the ability to use real-time data to spot suspected claims and providers and to take ation to stop fraudulent payments.
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