What Does CMS' Predictive Modeling System Entail?

CMS recently implemented a predictive analytics system that analyzes all Medicare claims to detect potentially fraudulent activity as of June 30, 2011, and a recent blog post by J. Paul Spencer on The RAConteur explains how this new method could affect healthcare providers.

Claims from June 30 and after are run through CMS' predictive modeling technology, and a risk score is created after all data are collected, according to the post. If a provider has a higher risk score, it could be subject to payment delays and visits from CMS. Harmless billing inconsistencies are recorded as such, followed by the payment.

However, if an analyst finds indications a case is suspicious, the case will be directed to CMS' Center for Program Integrity, the appropriate Medicare audit contractor and the appropriate zone program integrity contractor, the post explained.

Mr. Spencer said the crux of the new method is that the government is no longer using whistleblowers as the only source of a Medicare fraud case. Instead, technology associated with pre-screening methods within the banking and credit industry is now a part of the healthcare industry.

Related Articles on Medicare Fraud and Predictive Modeling:

CMS to Adopt Predictive Fraud-Fighting Technology July 1
GAO Study Outlines Key Strategies to Reduce Fraud in Medicare, Medicaid
Investigation Finds CMS Officials Rarely Attend Medicare Fraud Hearings

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