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At a Boston fraud-prevention summit, the Obama administration announced a plan to use predictive-modeling software to fight Medicare and Medicaid fraud.
eweek, By: Brian T. Horowitz, 2010-12-20
Taking a tip from banks, credit card firms and insurance companies, CMS (the Centers for Medicare and Medicaid Services) will implement predictive-modeling software to fight fraudulent claims for Medicare and Medicaid and the Children's Health Insurance program.
U.S. Department of Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder made the announcement at a health care fraud-prevention summit at the University of Massachusetts on Dec. 16.
"Simply put, we have taken our fight against health case fraud to a new level, and I am committed to continued collaboration, vigilance and progress," Attorney General Eric Holder said in a statement.
... CMS, an agency of HSS (Department of Health and Human Services), is currently seeking bidders from interested software vendors, according to Peter Ashkenaz, a spokesperson for CMS. Contracts will follow.
The new analytic tools will support the efforts of the HHS and HEAT (Department of Justice Health Care Fraud Prevention and Enforcement Action Team).
CMS has already used predictive modeling tools to halt payments to "false fronts" in Texas, according to the agency.
Another example involves a partnership between CMS and RATB (Federal Recovery Accountability and Transparency Board) to uncover high-risk providers. The effort spotted suspect providers by combing public data and relying on fraud alerts from courts and health care payers.
Read more.
A related WSJ story (Dec 22, 2010) Using a Computer to Fight Medicare Fraud
In 2007, criminal investigators and prosecutors vowed to revolutionize the way they fought health-care fraud: They would mine claims data to decide what cities, types of fraud and individual providers to target. ... Sifting through the billing records, red flags popped up on one of those companies, TA Medical Supply. A lot of the patients lived out of state, as did a lot of the referring doctors-two common possible indicators of fraud. A suspiciously large number of patients received orthotics for several parts of their bodies. But truly eye-popping was this fact: More than 96% of TA's patients who received braces for the knee, ankle, elbow or wrist got them on both their left and right sides.