CMS intends to take a bigger bite out of fraud and abuse by strengthening its monitoring and analytics capabilities to prevent and detect suspicious activities. CMS will be using the latest technologies for a fraud prevention system to scrutinize Medicare claims.
CMS is using the latest technologies for a fraud prevention system to scrutinize Medicare claims. This feeds into a risk-scoring solution, which assists in directing priorities for the agency’s anti-fraud recovery audit contractors (RACs) and for CMS to conduct analyses and investigations to determine what action is warranted. Contract awardee Northrop Grumman began operating the fraud prevention system in July, and IBM is developing and testing models that fit into the system.
CMS will also conduct analyses of providers who enroll in its programs, assign risk levels to them and make its enrollment system more automated to accommodate new data, such as Social Security death files and loss of licensure. The automated provider enrollment screening, which will replace the more manual system, will be operational in January.
A laboratory that CMS is building will examine historical and current data to identify the root causes of vulnerabilities so the agency can change policies as well as prevent future problems.
The agency also shares information broadly with states and law enforcement, including the Justice Department, Office of Inspector General and the FBI, and will move towards being able to do so with private plans, he said.
