HHS Secretary Kathleen Sebelius has announced that CMS will begin using new predictive modeling technology to help crack down on fraudulent Medicare claims before payment is made. Plans are for the new technology to roll out this year in ten states with the highest levels of waste, fraud, and abuse. By the third year of implementation, predictive modeling software will be incorporated into Medicare claims processing systems nationwide.
The initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act to help CMS move beyond its former “pay & chase” recovery operations. Medicare will adopt the state-of-the-art technology in predictive modeling systems that are currently used by the credit card and banking industries to identify potentially fraudulent claims and billing patterns before taxpayer funds are spent.
Northrop Grumman, a global provider of advanced information solutions was selected through a competitive procurement to develop the CMS national predictive model technology format. The company has partnered with National Government Services and Federal Network Systems, LLC, a Verizon company to fight healthcare fraud.
Northrop Grumman, through the use of proven predictive models and other advanced analytics, will move rapidly to implement the new technology. The company will deploy algorithms and an analytical process that looks at CMS claims by beneficiary, providers, service origin, or other patterns to identify potential problems and then assign alert and risk scores for those claims. The problem alerts will be further reviewed to allow CMS to both prioritize claims for additional review and then if necessary assess the need for investigative or other enforcement actions.