By Kelly A. Briganti, Editorial Director, G2 Intelligence
Analytics aren’t valuable just for improving business. The Centers for Medicare and Medicaid Services (CMS) announced this month that its Fraud Prevention System (FPS), an “advanced analytics system,” has uncovered or prevented $820 million in inappropriate payments. The FPS uses “predictive modeling and other analytics technologies to find and avoid payment of improper Medicare claims.” Using analytics in much the same way credit card companies do, the system finds “troublesome billing patterns and outlier claims.” CMS indicated in a press release that it intends to use the system not just to identify and prosecute fraud but also to ferret out potential payment issues that are not necessarily the result of illegal intentions but could be “better served by education or data transparency interventions.”
“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,” Acting CMS Administrator Andy Slavitt said in a press release. Referring to the system’s identification in 2014 of $454 million in improper payments, Slavitt declared: “Very few investments have a 10:1 return on taxpayer money.”
CMS explains that the analytics help spot potentially improper billing patterns and use information about past billing practices to find fraud. CMS Deputy Administrator and Director of the Center for Program Integrity Dr. Shantanu Agrawal emphasized the system’s ability to facilitate a more proactive approach to fighting fraud: “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.”
For more details about the third operational year for FPS and OIG recommendations about its future use, see the latest issue of National Intelligence Report.