CMS Reports $42 Billion in Savings
August 01, 2016
By Nancy Clark, CPC, COC, CPB, CPMA, CPC-I
- Provider enrollment and screening standards
- Utilization of the Affordable Care Act’s tools to allow for better screening of providers and suppliers that may be at risk for committing fraud
- Increasing site visits to enrolled providers and suppliers
- Enhanced address verification via the Provider Enrollment, Chain, and Ownership System (“PECOS”) software
- Deactivation of providers and suppliers that have not billed Medicare in the last 13 months
- Predictive analytics to prevent fraud, waste, and abuse
- Implementation of a Fraud Prevention System using data connections with public and private analytics experts to identify issues and take corrective action
- Predictive analytics technology contributed to more than $1 billion in savings from 2014 to 2015.
- Predictive analysis allows CMS to proactively deny claims that may not be appropriately reimbursable, and therefore saves the expense and time of “going after” the provider to return the inappropriate monies. In fiscal year 2013, savings from these preventive actions represented about 68% of total savings. In 2014, the savings rose to nearly 74%.
- Analyses are run on 4.5 million Medicare claims daily.
- CMS is now working on a next-generation predictive analytics system with improved efficiency.
- Coordination of anti-fraud efforts with federal and external partners
- CMS provides a forum for information exchange between federal, state, and private partners, receiving and disseminating data that will both reduce duplication of efforts and identify potential fraudulent activity across multiple payers.
- The Office of Inspector General Work Plan continues to identify additional areas in which CMS is reviewing claims.
- CMS contractors, state Medicaid agencies, and law enforcement partners offer and receive assistance in fraud prevention.