PREDICTIVE MODELING System to Decrease Fraud and Allow Prompt Payment

PREDICTIVE MODELING system to decrease fraud and allow prompt payment

• LMN Matters #SE1133 – for all entities– SBJA small business jobs act section 4241

• June 30, 2011 CMS implemented system to detect potential fraudulent activity before it happens.

• The system uses algorithms and models/real time/ flags suspicious billing. (Similar to credit card companies)

• a) analysts review claims history (b): conduct interviews with benes/docs/referral sources etc. – c) on sites as necessary --If no issues found they record outcome and release claims – the feedback loop refines the models and algorithms to better target fraudulent behavior.

• Analysts find indicators of fraud – refer to program integrity/ Macs/ & ZPICs to recoup/stop payment – if intent proven will revoke number --- Currently not denying claims but focused on developing and refining models that identify unusual behavior without disrupting claims processing.

• CMS is working with clinical experts and provider specialties across the country to develop and refine algorithms that reflect the complexities of medical treatment & billing.

• Good news for the honest providers/weed out the bad without injuring the honest companies.

• Predictive modeling allows for automated cross checks of providers/beneficiary & claims history & allows CMS to quickly identify and resolve problems without delay in payment.

• CMS states the agency remains dedicated to ensuring prompt payment (statutory requirement)