An innovative partnership has been formed between the federal government and several leading private and state organization to battle healthcare fraud. The partnerships share information and best practices to detect and prevent payment of fraudulent activities. Performing sophisticated analytics that will detect and predict fraud schemes are being put into place. This state-of-the-art technology and well-planned operation have already shown to be effective in cracking down on entities and individuals attempting to defraud Medicare, Medicaid, and private insurance plans.
The Centers for Medicare and Medicaid services (CMS) has implemented a new Automated Provider Screening (APS) system. The APS uses existing information from public and private sources to automatically and continuously verify information submitted on a provider's Medicare enrollment application including licensure status. In addition to the enhanced enrollment and screening requirements, the Secretary is now entitled to impose a temporary moratorium on newly enrolling providers or suppliers if necessary.
Anti-fraud provisions help to increase coordination among states, CMS, and its law enforcement partners. The law now authorizes CMS to suspend Medicare payments to providers or suppliers if there is a credible allegation of fraud. This initiative reverses a long-standing Medicare practice of paying claims then attempting to recoup funds if the claim is found to be an error or fraudulent. States must also withhold payments to Medicaid providers where there is a pending investigation of a credible allegation of fraud unless the state Medicaid agency has good cause not to do so.
To target resources to highly suspect behaviors, CMS has implemented a practice which uses advanced predictive modeling technology to fight fraud. Much like the predictive technologies used in the credit card industry, the Fraud Prevention System uses advanced technology to identify suspicious behavior and billing irregularities. This targets investigative resources on areas of vulnerability that demand immediate attention and response. By streaming claims on a prepayment basis, CMS and its investigative partners are able to more efficiently identify fraudulent claims and respond quickly to emerging trends.
Analytics, shared information and collaboration all contribute to the reduction of healthcare fraud. Tough New Rules and legal consequences for the fraud criminals increases the federal sentencing guidelines for health care fraud offenses by 20-50% for crimes that involve more than $1 million in losses. Penalties for obstructing a fraud investigation or audit make it easier for the government to recapture any funds acquired through fraudulent practices. In May 2012, Medicare Strike Force teams charged 107 individuals including doctors, nurses and other licensed medical professionals for their alleged participation in Medicare fraud schemes involving more than $452 million. This takedown involved the highest amount of false Medicare billings in a single takedown in strike force history. Success such as this will not only recoup wrongly paid claims but also aid in the prevention of future healthcare fraud.
The Centers for Medicare and Medicaid services (CMS) has implemented a new Automated Provider Screening (APS) system. The APS uses existing information from public and private sources to automatically and continuously verify information submitted on a provider's Medicare enrollment application including licensure status. In addition to the enhanced enrollment and screening requirements, the Secretary is now entitled to impose a temporary moratorium on newly enrolling providers or suppliers if necessary.
Anti-fraud provisions help to increase coordination among states, CMS, and its law enforcement partners. The law now authorizes CMS to suspend Medicare payments to providers or suppliers if there is a credible allegation of fraud. This initiative reverses a long-standing Medicare practice of paying claims then attempting to recoup funds if the claim is found to be an error or fraudulent. States must also withhold payments to Medicaid providers where there is a pending investigation of a credible allegation of fraud unless the state Medicaid agency has good cause not to do so.
To target resources to highly suspect behaviors, CMS has implemented a practice which uses advanced predictive modeling technology to fight fraud. Much like the predictive technologies used in the credit card industry, the Fraud Prevention System uses advanced technology to identify suspicious behavior and billing irregularities. This targets investigative resources on areas of vulnerability that demand immediate attention and response. By streaming claims on a prepayment basis, CMS and its investigative partners are able to more efficiently identify fraudulent claims and respond quickly to emerging trends.
Analytics, shared information and collaboration all contribute to the reduction of healthcare fraud. Tough New Rules and legal consequences for the fraud criminals increases the federal sentencing guidelines for health care fraud offenses by 20-50% for crimes that involve more than $1 million in losses. Penalties for obstructing a fraud investigation or audit make it easier for the government to recapture any funds acquired through fraudulent practices. In May 2012, Medicare Strike Force teams charged 107 individuals including doctors, nurses and other licensed medical professionals for their alleged participation in Medicare fraud schemes involving more than $452 million. This takedown involved the highest amount of false Medicare billings in a single takedown in strike force history. Success such as this will not only recoup wrongly paid claims but also aid in the prevention of future healthcare fraud.
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