Predictive Modeling Technology Replaces CMS’ ‘Pay & Chase’ Recovery Operations

This new-age technology will help agencies use real-time data to identify suspicious claims and take action then and there.

In what could be a big dampener for criminals looking to defraud Medicare, the Centers for Medicare and Medicaid (CMS) will use a ground-breaking predictive modeling technology starting July 1 to keep Medicare fraud, CMS announced in a June 17 release. “This new technology will help us better identify and prevent fraud and abuse before it happens and helps to ensure the solvency of the Medicare Trust Fund,” said CMS Administrator Donald Berwick, M.D in the release.

Background: This comes following President Obama’s campaign to do away with waste, fraud and abuse throughout the federal government. “This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made,” the release states.

How it’ll work: The agency will use pioneering risk scoring technology to assess original Medicare claims. In fact, this is the first time that the agency will use real-time data to detect suspect claims/providers and take steps immediately to curb fraudulent payments before they are paid, says the release.

Behind the scenes: The agency has contracted with Northrop Grumman, a global provider of advanced information solutions to develop its predictive modeling technology; the global provider has pulled in two other companies - National Government Services (NGS) and Federal Network Systems – to assist in this fraud prevention program, the release states.

The road ahead: Will this ‘prevent & pay’ approach replace the agency’s ‘pay & chase’ recovery operations successfully? Let’s wait and watch.

To view CMS’ press release, click here: http://www.cms.gov/apps/media/press/release.asp?Counter=3983&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&sr