Claims Analytics Help Medicare Identify, Prevent Provider Fraud
The use of a claims analytics platform helped Medicare to identify and prevent millions of dollars in provider fraud.
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By - Close to a quarter of new Medicare fraud investigations started with the use of a claims analytics platform that has helped to save approximately $6.7 million in incorrect billings, a new GAO report found.
After reviewing fraud prevention procedures and technologies within Medicare in 2016, GAO determined that the Fraud Prevention System (FPS) helped Medicare take corrective actions against 90 providers by suspending improper payments. The review also suggested that the FPS is helping CMS programs curb their historical fraud vulnerabilities.
“Since 1990, we have designated Medicare a high-risk program because of its size, complexity, and susceptibility to mismanagement and improper payments,” GAO said. “Some improper Medicare payments are due to fraud, which involves willful misrepresentation.”
Medicare contractors are hired to help open fraud investigations and identify fraudulent billing. These contractors identify leads from claims through referrals and the FPS, review the leads and analyze them for possible fraud, and then begin investigations when required.
FPS works by identifying rule violations for submitted Medicare claims (prepayment identification).
“For example, an FPS edit denies physician claims that improperly increase payments by misidentifying the place that the service was rendered, which helped address a payment vulnerability associated with millions in overpayments,” GAO explained.
Since May 2017, CMS has implemented 24 edits in FPS. The agency reported that the FPS edits denied nearly 324,000 claims and saved more than $20.4 million in 2016 before an investigation was needed to recover improper payments.
Medicare officials said that FPS speeds up the process for identifying and triaging providers suspected of fraud. However, FPS doesn’t speed up the length of investigations once they’re opened or change how fast the agency can gather evidence on providers.
The FPS was developed to support the data-sharing and claims analysis efforts of the Healthcare Fraud Prevention Partnership (HFPP), which GAO was also asked to review in their report.
The HFPP has extended data-sharing between payers and developed programs to identify fraudulent claims, codes, and directories of invalid providers.
As of June 2017, HFPP has 79 participants who agree that the partnership has helped their fraud prevention activities in several ways. Since 2012, HFPP has allowed payers and participating stakeholders to pool misused codes into datasets, create a database of non-operational providers, and identify regular overpayments for high-risk areas such as behavioral health services.
“Participants, including CMS officials, stated that sharing data and information within HFPP has been useful to their efforts to address health care fraud,” GAO said. “HFPP conducts studies that pool and analyze multiple payers’ claims data to identify providers with patterns of suspect billing across payers.”
“For example, one study identified providers who were cumulatively billing multiple payers for more services than could reasonably be rendered in a single day,” GAO continued. “Participants also stated that HFPP has fostered both formal and informal information sharing among payers.”
As agencies learn to incorporate effective data-sharing and claims analysis into their fraud prevention initiatives, Medicare and other CMS programs can continue to provide their members coverage without being predisposed to improper claims and criminal activities.
