GAO: Expect More CMS Fraud Investigations

Revenue Cycle Advisor, October 30, 2017

Nearly two-thirds of providers were affected by the CMS Fraud Prevention System in FY 2016. And the number of investigations is expected to rise.

This article was originally published October 4, 2017, by Revenue Cycle Advisor.

In fiscal year (FY) 2016, 65% of providers were subject to prepayment review associated with the CMS Fraud Prevention System (FPS), according to a U.S. Government Accountability Office (GAO) report. FPS relies on data analytics to compare claims against Medicare requirements. The automated system pinpoints payments that are potentially fraudulent and denies them through prepayment edits.

 “CMS reported that FPS edits denied nearly 324,000 claims and saved more than $20.4 million in FY 2016,” states the report.  In FY 2016, CMS referred 47% of overpayment determinations for collection.

There were 654 new investigations for 90 providers in FY 2016, which led to $6.7 million savings.  This was in part due to payments being suspended for 90 providers in FY 2016.

The number of investigations which led to administrative actions against providers was lower in FY 2016 (38%) than in FY 2015 (44%). However, according to the GAO, this number is expected to increase “as CMS changes program integrity contractor requirements for using FPS with the transition from Zone Program Integrity Contractors to Unified Program Integrity Contractors.”

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