Thanks to predictive analytics, crooks who file fraudulent claims hoping to take advantage of the Medicare and Medicaid systems are going to be out of luck.
This past summer, the feds started using predictive modeling software to flag these would-be bad guys before they get checks from us—you know, the taxpayers.
Instead of just evaluating one claim at time, the new system will help the government, specifically the Centers for Medicare & Medicaid Services (CMS), collect and analyze data to spot potential fraud. The technology, similar to the predictive modeling used by banking and telecommunications companies to spot fraud, is helping to identify potentially fraudulent Medicaid and Medicare claims across the county.
For the first time, CMS has the ability to use real-time data to spot suspect claims and providers and take action to stop fraudulent payments before they’re paid. The new system uses proven predictive models and other advanced analytics to analyze incoming Medicare claims—by beneficiary, provider, service origin or other patterns—to identify potential problems, create alerts and assign “risk scores” based on the data collected.
The claims that are flagged are then routed to CMS case managers who review the problem alerts then prioritize claims for additional review. A case manager can also choose to launch an investigation or take some enforcement action.
Those providers with higher risk scores will be subject to payment delays, followed site visits, reviews of claim histories and maybe even interviews by CMS analysts.
“If, after analyst intervention and inquisition, the billing is found to be “innocuous” that outcome is recorded into the predictive modeling system and the payment for the claim(s) in question is released as usual,” according to this blog post.
But if an analyst finds something’s not right with a claim, he’ll refer that case to someone higher up the food chain. And that’s not such good news for the provider because the claim could be denied and the provider’s billing privileges revoked.
But that’s not the worst of it.
Those providers could be on the receiving end of unannounced visits by the feds—read raids—their records could be confiscated and they could face civil, monetary penalties and jail.
So far, the predictive analytics technology seems to be working.
In September the feds announced that the Medicare Fraud Strike Force operations resulted in charges against 91 people who tried to bilk the Medicare system out of approximately $295 million.
A pretty good start for the good guys, I’d say.
Linda Rosencrance
Spotfire Blogging Team
