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CMS fraud unit uncovers $820 million in healthcare scams in past 3 years

The Fraud Prevention System uses predictive analytics to identify questionable billing patterns in real time.

Susan Morse, Senior Editor

The Fraud Prevention System uses predictive analytics to identify questionable billing patterns in real time.The Fraud Prevention System uses predictive analytics to identify questionable billing patterns in real time.

The Centers for Medicare & Medicaid Services on Tuesday said it has identified or prevented $820 million in inappropriate payments over the past three years through its  Fraud Prevention System.

More $454 million, was identified in 2014 alone, according to CMS.

The Fraud Prevention System uses predictive analytics to identify questionable billing patterns in real time. It can also review past patterns that may indicate fraud.

[Also: Running list of notable 2015 healthcare frauds]

CMS has been using the system, similar to those used by credit card companies, for three years.

Last month, the Fraud Prevention System led to the largest coordinated fraud takedown in CMS history. Forty-six doctors, nurses and other licensed professionals were among 243 individuals charged for their alleged participation in false Medicare billings of an estimated $712 million.

[Also: 243 healthcare professionals accused in $712 million 'biggest ever' fraud takedown]

The Fraud Prevention System also identified an ambulance provider for trips allegedly made to a hospital. During the three years prior to the system alerting officials, the provider was paid more than $1.5 million for transporting more than 4,500 beneficiaries.

A review of medical records found significant instances of insufficient or lack of documentation. CMS also revoked the provider’s Medicare enrollment and referred the results to law enforcement.

Over the last five years, more than $25 billion has been returned to the Medicare Trust Fund.

The system moves CMS beyond the “pay and chase model,” said Dr. Shantanu Agrawal, CMS deputy administrator and director of the Center for Program Integrity.

In future years, CMS plans to expand the Fraud Prevention System and its algorithms to identify lower levels of non-compliant health care providers who would be better served by education or data transparency interventions.

Twitter: @SusanMorseHFN

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