tci Medicare Compliance & Reimbursement - 2015 Issue 15

Industry Notes: CMS' Analytics System Caught $820 Million in Fraud

CMS uses many approaches to catching fraud, and its high-tech analytics system is one of the most lucrative tools for the agency. On July 14, CMS announced that its Fraud Prevention System identified or prevented $820 million in inappropriate payments over a three-year period, with $454 million of that amount in just 2014 alone. The system uses analytics software to identify questionable billing patterns among Medicare claim submissions. “In one case, one of the system’s predictive models identified a questionable billing pattern at a provider for podiatry services that resulted in Medicare revoking the provider’s payments...

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