For example, the system found a radiologist billing Medicare for care he never provided. It also detected a chiropractor who was filing claims for more patients than he could possibly see in a day. The system also shone the spotlight on a case involving a family physician egregiously doing the same. Billing “spikes”—or sudden increases—in healthcare claims by these and other healthcare providers nationwide alerted us of related billing trends. A more recent alert identified claims from an ambulance company billing for patient “trips to nowhere.” Through cases like this, the CMS is seeing impressive results nationwide. This predictive analytics technology contributed to more than $1 billion in savings in 2014 and 2015.
The Fraud Prevention System, or FPS, is innovative in that we have moved beyond the reactive “pay and chase” approach toward a more effective, proactive strategy that aims to prevent these illegitimate payments in the first place. Since its June 2011 inception, the FPS has identified significant savings by running sophisticated analytics on 4.5 million Medicare claims on a daily basis, prior to payment. Year after year, the FPS has continued to improve its ability to identify or prevent fraud. Since the beginning of the program, over $1.5 billion in inappropriate payments has been identified by the system through new leads or contributions to existing investigations. Also, in 2015, the CMS marked its first-ever national return-on-investment of $11.60 for every dollar the federal government spends on this program integrity system.
As we moved toward preventing inappropriate payments, we also successfully developed ways to measure costs avoided due to removing certain providers from the Medicare program and tracking return on investment. These methodologies to calculate cost avoidance have achieved certification by HHS' Office of Inspector General, the first such certification in the history of federal healthcare programs.
The CMS is now working to develop next-generation predictive analytics with a new system design that even further improves the usability and efficiency of the FPS. Using it and other advanced tools, we are committed to addressing fraud, waste and abuse in the Medicare program to better protect beneficiaries and taxpayers.
At the CMS, Dr. Shantanu Agrawal is deputy administrator and director of the Center for Program Integrity; Raymond Wedgeworth is director of the Data Analytics and Systems Group; and Kelly D. Bowman is the Center for Program Integrity's senior adviser.
