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CMS to introduce new fraud-fighting tools

The Centers for Medicare & Medicaid Services will soon be outfitted with new state-of-the-art fraud fighting analytic tools to prevent wasteful and fraudulent payments in Medicare, Medicaid and the Children's Health Insurance Program.

HHS Secretary Sebelius and Attorney General Eric Holder issued a solicitation for the tools at the fourth regional healthcare fraud prevention summit in Boston on Thursday. Officials said the tools will integrate many of the Agency's pilot programs into the National Fraud Prevention Program and complement the work of the joint HHS and Department of Justice Health Care Fraud Prevention and Enforcement Action Team (HEAT).

Sebelius and Holder have crisscrossed the country this year bringing together a wide array of federal, state and local partners, beneficiaries, and providers to discuss innovative ways to eliminate fraud within the U.S. healthcare system.

"This has been a remarkable year for cracking down on healthcare fraud – and our success has been built on initiatives like these combining the experience and insight of our law enforcement teams with new resources and cutting-edge technology," said Sebelius. "Thanks to the new tools and resources provided under the Affordable Care Act, we are more effective at going after the fraudsters that are stealing taxpayer dollars."

"Here in Boston and in communities across the country, healthcare fraud schemes are being aggressively and permanently shut down," said Holder. "The District of Massachusetts, with U.S. Attorney Carmen Ortiz at its helm, has recovered more than $4 billion in civil and criminal healthcare fraud settlements over the past two years.

"These actions are in large part because of the great work being led by Health Care Fraud Prevention and Enforcement Action Team," Holder added. "Through this initiative, we are working in partnership with government, law enforcement and industry leaders to protect taxpayer dollars, control healthcare costs, and ensure the strength and integrity of our most essential health care programs. Simply put, we have taken our fight against health case fraud to a new level, and I am committed to continued collaboration, vigilance, and progress."

Currently banks, credit card companies, insurance and other consumer companies are using predictive modeling tools to identify potential fraud before it occurs. CMS said it is now actively exploring using similar systems to identify background information on potential fraudulent actors and links to questionable affiliations. This type of new information will help prevent bad actors from enrolling as healthcare providers or suppliers. Other tools will track billing patterns and other information to identify real-time aberrant trends that are indicative of fraud.

"Preventing fraud is more effective than the old 'pay and chase' model of fighting fraud after a sham provider has been paid and disappeared," said CMS Administrator Donald Berwick, MD. "By using new predictive modeling analytic tools we are better able to expand our efforts to save the millions – and possibly billions – of dollars wasted on waste, fraud and abuse."

CMS will use the results to take anti-fraud actions before a claim is paid, and is already starting to take administrative action to stop payments to "false fronts" in Texas identified through sophisticated predictive modeling. CMS is also implementing new and expanded authority provided in the Affordable Care Act to take such actions, including suspending payments when investigating a credible allegation of fraud.

"Using the most up-to-date technologies and adopting best practices across the nation's healthcare system, we have a better chance of finding fraudulent and abusive providers before they even start billing Medicare or other health insurance," said Peter Budetti, MD, director of CMS' Center for Program Integrity.

Many companies in the private sector, as well as CMS, have been testing and using predictive modeling programs to help identify possible fraudulent providers and scams based on historical information about the individual or the company in which the individual is affiliated.

In one pilot program, CMS partnered with the Federal Recovery Accountability and Transparency Board (RATB) to investigate a group of high-risk providers. By linking public data (information found by anyone on the Internet) with other information like fraud alerts from other payers and existing court records, a sophisticated, potentially fraudulent, scheme was uncovered. The scheme involved opening multiple companies at the same location on the same day using provider numbers of physicians in other states. The data confirmed several suspect providers who were already under investigation and, through linkage analysis, identified affiliated providers who are now also under investigation.

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