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Late News: CMS efforts to move to new anti-fraud system delayed


By Modern Healthcare
Posted: November 17, 2012 - 12:01 am ET
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The centerpiece of the CMS' efforts to move from a pay-and-chase anti-fraud system to an advanced $90 million predictive-modeling system will be delayed for at least six months, according to congressional auditors. The nonpartisan Government Accountability Office investigated the status of the CMS Fraud Prevention System after Republican senators said their questions on its implementation were ignored. The GAO found the program missed a July start date and will not begin fully operating until at least January. The report shows the CMS “has fallen short of the congressional requirement to prevent fraudulent Medicare payments before they are made, as opposed to having to chase down crooks after the money has gone out the door,” Sen. Scott Brown (R-Mass.) said in a news release. Authorized by the Small Business Jobs Act of 2010, the system was intended to filter Medicare fee-for-service claims data through predictive analytic models, which use historic Medicare claims and other data to identify high-risk claims and providers. The agency awarded two contracts in 2011 for a total of $90 million for companies to build the system, which began reviewing Medicare claims but was never connected to a payment denial system “due to the time required to develop system requirements,” according to the GAO report. The CMS “estimated that it will be implemented by January 2013 but had not yet developed reliable schedules for completing this activity,” the GAO report said. CMS officials noted that information from the partially implemented system has been provided to zone program integrity contractors for their traditional after-the-fact audits.

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