CMS announces implementation of new fraud-fighting technology

Beginning July 1, the Centers for Medicare & Medicaid Services (CMS) will begin using new predictive modeling tools to root out fraudulent Medicare claims. CMS says its approach is based on using real-time data to identify fraud as credit card companies do. Last year’s Small Business Jobs Act of 2010 provided funding – $100 million – for CMS to implement this technology.

The agency contracted with Northrop Grumman to develop processes to review claims by beneficiary, provider, service origin or other patterns and identify potential problems. Claims that raise concerns will be flagged and assigned a “risk score,” which will determine the agency’s next steps before it pays the claim. While CMS originally planned to roll out the program gradually, it announced last week that it will go nationwide on July 1. 

How do practices know that this new technology will not interfere with timely payment of legitimate claims, if CMS won’t disclosed any detailed information regarding how the technology will be used. CMS usually rolls new technolgy out to a pilot group first. Not this time, they are rolling this out nationwide. I see cash flow issues for those physician practices who treat large volumes of Medicare & Medicaid patients.

To date, the government has not provided adequate details on this program. Click Here for the official CMS press release.

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