by Angela Guess
Dr. Shantanu Agrawal, Raymond Wedgeworth, and Kelly D. Bowman recently wrote in Modern Healthcare, “Over the past five years, the CMS [Centers for Medicare & Medicaid Services] has successfully implemented a Fraud Prevention System using ‘big data’ and predictive analytics approaches to fight fraud, waste and abuse in the Medicare fee-for-service program. Taking ‘big data’ mainstream has given the CMS the ability to better connect with public and private predictive analytics experts and data scientists, as well as collaborate more closely with law enforcement. The Fraud Prevention System’s “big data” effort has had a profound impact on fraudulent providers and illegitimate payments by allowing us to quickly identify issues and take action.”
They continue, “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.”
Photo credit: CMS