Medicare Compliance & Reimbursement

Predictive analytics spot over-billing and more, leading to revocation.

With crystal ball-like abilities, the Centers for Medicare & Medicaid Services (CMS) is catching improper payments before it even sends them to you. Here are a few of the cases that the Fraud Prevention System (FPS) has identified:

• Services not rendered: The FPS’s “big data” and predictive analytics identified a Florida home health agency that billed for services that it never rendered. CMS placed the agency on prepayment review and payment suspension, and then referred the agency to law enforcement and revoked its Medicare enrollment.
• Non-covered services: The FPS spotted claims for non-covered services and services not rendered from an ambulance company in Texas. CMS revoked the ambulance company’s Medicare enrollment.
• Over-billing: The FPS identified questionable billing practices, such as billing excessive units of services per beneficiary visit, by a medical clinic in Arizona. CMS reviewed the clinic’s medical records and discovered that the physicians had delivered repeated and unnecessary neuropathy treatments to patients. CMS revoked the clinic’s Medicare enrollment in 2015.

Takeaway: With these kinds of results, the FPS and its “big data” capabilities are here to stay. Keep your Medicare claims on the up-and-up if you don’t want to become the FPS’s next victim — the consequences are real and severe.