Medicare Compliance & Reimbursement

On Feb. 26, the HHS Office of the Inspector General (OIG) released its Health Care Fraud and Abuse Control Program Report FY 2015, which outlines the agency’s fraud prevention programs, as well as its significant recoveries in 2015. The agency also released a Fact Sheet the same day to highlight its findings. Key among the information was a paragraph in which the agency stressed how strongly it relies on “predictive analytics” to ferret out billing anomalies.

Many analysts felt that the focus on the Fraud Prevention System (FPS) was in direct response to the House Ways and Means Committee’s October letter asking CMS to update the FPS to collect more money. Although the new Fact Sheet didn’t indicate that any new technology would be added to collect more revenue, it was clear that CMS and the OIG are still very reliant on the FPS for raking in income.

“Since June 2011, CMS uses the FPS on all Medicare fee-for-service claims on a streaming, national basis,” the OIG said in its Fact Sheet. “Similar to the fraud detection technology used by credit card companies, FPS applies predictive analytics to claims before making payments in order to identify aberrant and suspicious billing patterns. CMS uses leads generated by FPS to trigger actions that can be implemented swiftly. Early results from FPS show significant promise. Since 2011, the FPS-identified savings (certified by HHS OIG) associated with these prevention and detection actions were $820 million. This resulted in more than a 10-to-1 return on investment for the first three years of implementation.”

Resource: To read the OIG’s complete fraud report for 2015, visit http://oig.hhs.gov/publications/docs/hcfac/FY2015-hcfac.pdf.