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Feds Seek Anti-Fraud Technologies to Nab Medicare Cheats

Cheryl Clark, for HealthLeaders Media, December 17, 2010

"Preventing fraud is more effective than the old 'pay-and-chase' model of fighting fraud after a sham provider has been paid and disappeared," said CMS Administrator Donald Berwick, MD. "By using new predictive modeling analytic tools, we are better able to expand our efforts to save the millions – and possibly billions – of dollars wasted on waste, fraud and abuse."

In one pilot program CMS has partnered with the Federal Recovery Accountability and Transparency Board to investigate a group of "high-risk" providers. By linking public data with other information like fraud alerts from other payers and existing court records, they uncovered "a sophisticated potentially fraudulent scheme" in which several suspect providers who were already under investigation were found to have opened up multiple companies at the same location, on the same day. They used provider numbers of physicians in other states.

The effort also identified other providers who are now under investigation as well.

The Affordable Care Act provides another $350 million over the next 10 years specifically to fight fraud and abuse involving federal dollars. In its statement, HHS says the act "toughens sentencing for criminal activity, enhances screenings and enrollment requirements, encourages increased sharing of data across government, expands overpayment recovery efforts, and provides greater oversight of private insurance abuses.

"Efforts in fraud detection and enforcement pay for themselves many times over," the statement said.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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