by clicking on the page. A slider will appear, allowing you to adjust your zoom level. Return to the original size by clicking on the page again.
the page around when zoomed in by dragging it.
the zoom using the slider on the top right.
by clicking on the zoomed-in page.
by entering text in the search field and click on "In This Issue" or "All Issues" to search the current issue or the archive of back issues respectively.
by clicking on thumbnails to select pages, and then press the print button.
this publication and page.
displays a table of sections with thumbnails and descriptions.
displays thumbnails of every page in the issue. Click on a page to jump.
allows you to browse through every available issue.
GCN : September 2014
ANTI-FRAUD TACTICS In its second year of using its Fraud Pre- vention System (FPS), the Centers for Medicare and Medicaid Services identi- fied or prevented $210 million in improper Medicare payments, according to a CMS report to Congress on fraud prevention re- leased in June. The agency's success can be attributed to two main features of FPS that set it apart from other fraud prevention sys- tems, health payer analysts say. "What makes this system a little bit dif- ferent from many others, especially at this progression now, is that they try to iden- tify the fraud before [payment] goes out," said Ryan Blaney, a member of the Health Law group at law firm Cozen O'Connor's Washington, D.C., office. "The other big difference is that it's combining multiple systems working simultaneously." FPS uses predictive algorithms to com- pare billing patterns against Medicare parts A and B fee-for-service claims prior to payment. The system is integrated with a Medicare claims processing system and other data sources, such as the Compro- mised Numbers Checklist of stolen provid- er identification numbers, the Fraud Inves- tigation Database and complaints from the Medicare call center. Another important resource is the Inte- grated Data Repository, which CMS stood up in 2006 as a storehouse of Medicare data. Currently, FPS monitors fraud, waste and abuse via 74 models running simul- taneously. In the past year, CMS added 39 models to the system, eight of which are predictive systems. Those are the most useful, Blaney said, because economists and engineers generate them by taking known cases of fraud and developing al- gorithms to identify claims that are more likely to be fraudulent than others. "A single predictive model is often as ef- fective as multiple non-predictive models," the report states. When FPS detects a problem, it gener- ates an alert. Then, CMS' Zone Program Integrity Contractors begin investigating based on flagged providers that generate the most suspicion. Last year, CMS took administrative action against 938 provid- ers and suppliers thanks to FPS. The $210 million saved, almost double the amount identified during FPS' first year in use, resulted in more than a $5 to $1 return on investment, up from last year's $3 to $1 return, the report states. The models come from CMS's Analytics Lab, where teams of economists, statisti- cians and programmers develop and test them with the help of policy experts. CMS has used analytics to identify po- tential fraud before, but each model was run separately in a specific region of the country, the report states. In contrast, FPS runs the models simultaneously and con- tinuously and with a national focus. Commercial companies are also work- ing to help the government detect and prevent fraud. For example, analytics com- pany 21CT will launch a health care fraud detection solution early next month. IBM and CoreLogic also have fraud prevention solutions targeted to the government. Moreover, fraud prevention isn't for the health care sector alone. The Financial Fraud Enforcement Task Force, created in November 2009 by President Obama in response to the financial crisis, has Stop- Fraud.gov, an online reporting tool broken down into categories such as mail fraud and cyber crime. FPS sets a great example for other agen- cies and companies looking to thwart fraud, Blaney said. "One of the advantages that health care has over some other agen- cies is a massive database of claims sub- missions," he said. "CMS has this robust database of infor- mation that they can take advantage of to run and help identify fraud," he added. "I think that coordination and the use of big data can really go a long way, and it will in the future." • Medicare has prevented over $200 million in payment fraud by amassing case data early and combining multiple data systems How CMS takes on and heads off Medicare fraud BY STEPHANIE KANOWITZ "One of the advantages that health care has over some other agencies is a massive database of claims." -- RYAN BLANEY, LAW FIRM OF COZEN O'CONNOR GCN SEPTEMBER 2014 • GCN.COM 31