tci Medicare Compliance & Reimbursement - 2011 Issue 22

Compliance: Part B MACs Now Using 'Predictive Modeling' of Claims to Catch Fraud

Fortunately, software alone won't be responsible for nabbing claim issues. Don't ever accuse CMS of being unsophisticated, at least from a software standpoint. The agency announced last week that Part B MACs have been using predictive analyses to scan your claims and potentially detect fraud, according to MLN Matters article SE1133. "As of June 30, 2011, CMS is streaming all Medicare FFS claims through its predictive modeling technology," the article notes. "As each claim streams through the predictive modeling system, the system builds profiles of providers, networks, billing patterns, and beneficiary utilization. These profiles enable CMS to create...

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