CMS uses data to thwart $820M in fraud

Tuesday, July 14, 2015

WASHINGTON – CMS’s Fraud Prevention System has identified and prevented $820 million in inappropriate payments in three years of use, the agency announced today. In 2014 alone, the system identified or prevented $454 million in inappropriate payments, a 10 to 1 return on investment, it says. “We are proving that in a modern health care system you can both fight fraud and avoid creating hassles for the vast majority of physicians who simply want to get paid for services rendered,” said Andy Slavitt, acting administrator of CMS. “The key is data.” The system uses predictive analytics to identify troublesome billing patterns and outlier claims for action similar to systems used by credit card companies. Going forward, CMS plans to expand the system and its algorithms to identify lower levels of non-compliant healthcare providers who would be better served by education or data transparency interventions.