Medicare Anti-Fraud Efforts Hit

GAO Report Highlights Data Repository Delays
Medicare Anti-Fraud Efforts Hit
The Government Accountability Office has issued a report chastising the Centers for Medicare and Medicaid Services for delays in fully implementing its Integrated Data Repository used to crack down on fraud.

The central repository is designed to help detect improper payments of claims. Analysts use the data to identify patterns of unusual activities or transactions that may indicate fraudulent charges or other types of improper payments, according to the report.

Although the repository has been operational since 2006, it does not yet include all the data that was slated to be gathered by fiscal 2010, the GAO found. For example, while it includes data on most types of Medicare claims, it lacks Medicaid data needed to detect improper payments. Plus, it lacks data from other CMS systems, such as information about claims at the time they are filed and being processed.

The repository is used in conjunction with One Program Integrity, a web portal that provides CMS staff and contractors with a single source of access to the data. The GAO reports, however, that "few program integrity analysts were trained and using the system." As of October 2010, less than 7 percent of available analysts were using the portal and tools, the GAO found.

The report also concludes: "While CMS has made progress toward its goals to provide a single repository of data and enhanced analytical capabilities for program integrity efforts, the agency is not yet positioned to identify, measure and track benefits realized from its efforts."

Thus, the GAO recommends that CMS "take steps to finalize plans and reliable schedules for fully implementing and expanding the use of the systems and to define measureable benefits." In its comments, CMS concurred with the GAO recommendations.

Predictive Modeling

In another anti-fraud effort, CMS recently announced plans to use predictive modeling technology to help identify fraudulent Medicare claims before they're paid (see: Medicare Turns to Predictive Modeling).

CMS entered a contract with Northrop Grumman to lead the technology effort in partnership with National Government Services and Federal Network Systems, a Verizon company. Starting this month, Medicare claims will be analyzed using risk-scoring technology that applies predictive models, an approach similar to that used in the private sector to identify credit card fraud.


About the Author

Howard Anderson

Howard Anderson

News Editor, ISMG

Anderson is news editor of Information Security Media Group and was founding editor of HealthcareInfoSecurity and DataBreachToday. He has more than 40 years of journalism experience, with a focus on healthcare information technology issues. Before launching HealthcareInfoSecurity, he served as founding editor of Health Data Management magazine, where he worked for 17 years, and he served in leadership roles at several other healthcare magazines and newspapers.




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