<p>PREDICTIVE MODELING system to decrease fraud and allow prompt payment</p><p>• LMN Matters #SE1133 – for all entities– SBJA small business jobs act section 4241</p><p>• June 30, 2011 CMS implemented system to detect potential fraudulent activity before it happens.</p><p>• The system uses algorithms and models/real time/ flags suspicious billing. (Similar to credit card companies) </p><p>• 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. </p><p>• 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. </p><p>• 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.</p><p>• Good news for the honest providers/weed out the bad without injuring the honest companies.</p><p>• Predictive modeling allows for automated cross checks of providers/beneficiary & claims history & allows CMS to quickly identify and resolve problems without delay in payment. </p><p>• CMS states the agency remains dedicated to ensuring prompt payment (statutory requirement)</p>