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GCN : July 2015
PHOTOCREDITHERESHUTTERSTOCK/1105MEDIA GCN JULY 2015 • GCN.COM 25 Health care fraud is one of the gov- ernment’s costliest problems. It’s a hall of mirrors where billions of dollars are lost to swindlers looking to cash in on the millions of transactions gener- ated by insurance-paying agencies ev- ery day. Last year, the federal government lost $124.7 billion in fraudulent or improper payments through 124 pro- grams, according to the House Ways and Means Committee’s Oversight Sub- committee. Medicare fraud accounted for about half, or $60 billion, of the losses. Behind that backdrop, for the past three years officials at the Centers for Medicare and Medicaid Services (CMS) have been working on a system designed to scan for clues to fraud in aggregated claims data. The Fraud Pre- vention System (FPS) flags anomalies before a payment is made, much like credit industry systems can spot a po- tentially fraudulent charge and with- hold payment while the transaction is investigated. FPS’ developers say the system’s biggest challenge could be the sheer complexity of the government’s health care payment system. According to the National Health Care Anti-Fraud Asso- ciation, Medicare Parts A and B process 4.5 million claims every day from 1.5 million health care providers, which means fraudulent patient records and treatments could slip through. “Preventing fraud is so difficult be- cause the schemes and participants are constantly...evolving to elude enforce- ment actions,” Charlene Frizzera, pres- ident of CF Health Advisors, told the subcommittee. As FPS continues to grow, compa- nies are also building new analytics tools that identify fraud more quickly, accurately and earlier in the payment cycle. Those companies cite advances in predictive analytics to flag probable fraud leads, case-management plat- forms to help assess risk throughout a fraud case and a greater emphasis THE FIGHT AGAINST HEALTH CARE FRAUD Government and industry are developing increasingly sophisticated tools to see beyond the smoke screen of fraudulent claims for medical payments BY PAUL McCLOSKEY “ The concept of continuous monitoring is what everyone is now waking up to.” An individual whose security status is not updated “can do significant damage in 10 years.” RAJ ANANTHANPILLAI, INFOZEN 0715gcn_024-028.indd 25 6/30/15 2:30 PM