Medicare Anti-Fraud Efforts HitGAO Report Highlights Data Repository Delays
The central repository is designed to help detect improper payments of claims. Analysts use the data to identify patterns of unusual activities or transactions that may indicate fraudulent charges or other types of improper payments, according to the report.
Although the repository has been operational since 2006, it does not yet include all the data that was slated to be gathered by fiscal 2010, the GAO found. For example, while it includes data on most types of Medicare claims, it lacks Medicaid data needed to detect improper payments. Plus, it lacks data from other CMS systems, such as information about claims at the time they are filed and being processed.
The repository is used in conjunction with One Program Integrity, a web portal that provides CMS staff and contractors with a single source of access to the data. The GAO reports, however, that "few program integrity analysts were trained and using the system." As of October 2010, less than 7 percent of available analysts were using the portal and tools, the GAO found.
The report also concludes: "While CMS has made progress toward its goals to provide a single repository of data and enhanced analytical capabilities for program integrity efforts, the agency is not yet positioned to identify, measure and track benefits realized from its efforts."
Thus, the GAO recommends that CMS "take steps to finalize plans and reliable schedules for fully implementing and expanding the use of the systems and to define measureable benefits." In its comments, CMS concurred with the GAO recommendations.
Predictive ModelingIn another anti-fraud effort, CMS recently announced plans to use predictive modeling technology to help identify fraudulent Medicare claims before they're paid (see: Medicare Turns to Predictive Modeling).
CMS entered a contract with Northrop Grumman to lead the technology effort in partnership with National Government Services and Federal Network Systems, a Verizon company. Starting this month, Medicare claims will be analyzed using risk-scoring technology that applies predictive models, an approach similar to that used in the private sector to identify credit card fraud.