Find-A-Code Focus Newsletter

Changes to Medicare Fraud System Announced

August 25, 2011

Last year there was a record $4 billion collected in the recovery program.  New tools authorized by the Affordable Care Act give CMS further power to fight fraud.  An announcement published on August 12, 2011, said:

“Fraud prevention efforts focus on moving CMS beyond its former "pay and chase" recovery operations to a more proactive "prevention and detection" model that will help prevent fraud and abuse before payment is made. A good example is the recent CMS announcement that for the first time, through the use of innovative predictive modeling technology similar to that used by credit card companies, the agency will have the ability to use risk scoring techniques to flag high risk claims and providers for additional review and take action to stop payments and remove providers from the program when necessary. "

This concept of risk scoring techniques is a little disconcerting. If you've ever had an incorrect ding on your credit record, you know what a pain it is to get it cleared up.  It is not uncommon for doctors with similar names in similar locations to have problems with insurance companies and services getting paid or not paid because of name confusion. Hopefully, CMS will setup easy to understand procedures to help innocent providers clear their names quickly.


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