2010 Idea Factory Pilot
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Audit claims data using fraud detection software which is used widely the private insurance industry
Audit/screen claims data for suspect fraud every month using a fraud detection software that will identify unbundling of codes, inappropriate procedures for age and/or sex and other common fraudelent practices. This strategy is widely used by the private health insurance industry.
67 votesCPI is implementing the National Fraud Prevention Program, a comprehensive strategy to leverage existing systems by integrating the data and new tools in innovative ways. An important aspect of this strategy is partnering with the private sector to learn about their capabilities. CPI issued a request for information in the winter of 2011 on best practices from the private sector, and has used that information to develop solicitations for contractors to adapt those solutions to the Medicare program.
Additionally, a contract will be awarded to begin the development of a risk scoring model that will screen claims and providers based on effective predictive models.
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Add an interview step to provider enrollment.
Utilize outstationed CMS financial staff to conduct onsite interviews of new providers or those flagged/suspect to validate their legitimacy (performing in a business-like manner, can demonstrate the capability to provide their services, known and/or respected members of the medical or business community in their area).
43 votesCPI recently implemented the requirement that certain providers will undergo site visits, announced and unannounced, prior to enrollment. The provider types are identified in CMS-6028-FC, and include DMEPOS suppliers, Home Health Agencies, Community Mental Health Centers and Ambulance Providers. CMS also has authority to perform a site visit at any time on any provider if there is reason to suspect fraudulent or illegitimate behavior that is best confirmed by an on-site visit.
CPI is considering innovative solutions to conducting site visits like the suggestion to use CMS Staff in the regional offices. CPI just concluded a Request for Information on Site Visits and is currently evaluating responses.
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Dramatically Increase Pre-Payment Review
Especially in high-risk areas (i.e. Miami and L.A) pre-pay reviews should become the standard. It would be time consuming and pricey for CMS to implement. However, the ROI would likely be remarkable as billions of dollars of fraud, waste and abuse would be saved (or never paid). There are far too many unscrupulous providers in certain areas of our country. Pre-payment reviews would not only save us from paying their fraudulant claims, it would also help us to identify and punish these individuals.
38 votesReferred to CMS Employee Suggestion Program for consideration by OFM/PCG.
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Compile fraud profiles based on data pulled from CMS/IRS/state Medicaid etc. and use to ID new fraud
Pull data from across platforms, including 1-800-Medicare, mymedicare.gov, IRS data, state Medicaid and other claims. Create profiles from known fraud cases and use new data to inform and pursue potential cases of fraud.
18 votesCPI is working to develop just these types of fraud profiles both for individuals and for the identification of new schemes. The National Fraud Prevention Program is designed to incorporate lessons learned on an on-going basis through a continual feedback loop in the analytics.
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Look at DISTRIBUTIONS of USAGE by COUNTY. Outliers indicate fraud
Look at DISTRIBUTIONS of usage by county. Distribution is typically in a band and very stable Outliers point to fraud.Past used. Further support given by follow up interviews
13 votesZone Program Integrity Contractors are already conducting this analysis.
CPI is additionally working to develop algorithms that will layer outliers with other information to refine the accuracy and efficiency of CMS’s data analytic work.
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11 votes
Referred to the Employee Suggestion Program.
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Clean up and Standardize Medicaid and CHIP data. Create CM Master Beneficiary and Provider Profiles
Create CMS Enterprise Beneficiary and Provider Profiles to include CHIP, Medicaid, and Medicare data
9 votesOIS responded that your idea is currently in the planning and early development phases. The vision of the Master Data Management (MDM) system is to use modern data engineering methods and tools to provide complete profiles of Medicare, Medicaid and Children’s Health Insurance Program data. The MDM system will offer a suite of services that will allow CMS to link and synchronize Beneficiary, Provider, and Organization data from multiple disparate sources.
Provider and Beneficiary profiles, or Books of Records, will be obtainable through a single call to a trusted, authoritative data service that is part of the MDM system. Additional cost estimates to include Medicaid/CHIP data into the MDM has been estimated to be $60Million dollars over several years.
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Fraud and Abuse Whistleblower hotline/website
Allow average americans who are concerned with the state of healthcare in this country to participate bringing integrity back into healthcare. Set up controlled criteria for submissions at first and overtime open up other categories
8 votesCMS has an incentive reward program for beneficiaries who report fraud that results in collected overpayments. These complaints can come through 1-800 Medicare and the OIG Tip Hotline.
Individuals are eligible to receive a reward of up to 10% or $1,000, whichever is less, if:
- the provider they reported is not currently under investigation by law enforcement or CMS contractors
- the complaint results in referral to law enforcement
- the investigation leads to the recovery of at least $100CPI does agree this program should be more actively promoted, and is working on a strategy to revitalize the program.
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Convince White House & Congress that fraud is top priority & change laws to make it so.
We need to convince the Public, Clinicians, the White House and Congress that fighting fraud, waste and abuse must be top priority.
Currently, as we make it easier for providers to submit claims and get paid, the unintended consequences include making it easier to commit fraud, waste and abuse.
7 votesCPI agrees that fighting fraud, waste and abuse should be a top priority. We believe that program integrity has gotten unprecedented attention since the passage of the Affordable Care Act last March.
Title VI of ACA has provided CMS with some very powerful tools that we are working diligently to implement – including increased screening requirements, the ability to suspend payments pending the investigation of a credible allegation of fraud, and the ability to impose a temporary enrollment moratoria to counteract an increased risk of fraud, waste of abuse to the federal health care programs. These authorities were implemented in CMS-6028-FC published this fall, and CPI intends to publish additional NPRMs implementing ACA authorities this fall and winter.
Additionally, the President’s Executive Order to reduce improper payments government wide requires CMS to cut the Medicare improper payment rate by 50% by 2014. Secretary Sebelius has directed the Department to…
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Create one SUPER database to house all Medicare and Medicaid claims data
Because claims data is widely dispersed with no central repository, this allows for fraud,waste and abuse to happen without a central intelligence overseeing trends and patterns in both Medicare and Medicaid data (including managed care data!). In the spirit of uniformity and Health Reform-we must move towards a centralized data warehouse where we can keep our eyes on the claims and utilization.
6 votesOIS responded that this idea is in current development. The vision of the Integrated Data Repository (IDR) is exactly that of a super claims database that will house ALL Medicare and Medicaid claims (encounters) data. To date, the IDR project has successfully populated Medicare claims and supporting Beneficiary data. Medicaid and Encounter claims data proposed in your suggestion will be populated in the near future, pending funds.
OIS agrees that CMS will greatly benefit from a database that contains all of the claims data submitted. As there have been several calls for a national level database not only for fraud, waste, and abuse purposes, but also for researchers, policy makers, actuaries, etc. The simplicity of the concept is that a user would have access to all the data required in a single location without the complications of complex middleware. The technology supporting IDR is capable of completing this…
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Tighten standards for successful claims appeals.
CMS’s efforts to obtain billing compliance from doctors and to establish more uniform application of Medicare policies are hindered by idiosyncratic appeal decisions, particularly at the Administrative Law Judge level. Not infrequently, the appeals decisions are made in favor of granting payments that at odds with both expressed and intended Medicare policy. A result of those decisions is that precedents may be established to make those policies unenforceable. Furthermore, a loose application of policy and lack of deference to a reasonable decision made by medical reviewers or lower level appeal venue encourages providers that bill aggressively to maximize revenue by…
6 votesCPI agrees that there is an area of vulnerability if the appeals standards appear to be inconsistent or frequently overturned. CPI is in the process of setting up a workgroup to address these concerns.
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CMS would focus more on evidence based decision making
CMS routinely conducts audits of Medicare Advantage plans. However, CMS would focus more on the audit findings to make policy decisions. In terms of claims fraud, CMS would ensure staff are competent in this area. Everyone that conducts audits may not know what a CPT code is and how it relates to the claim. Additionally, CMS would consider finding and appraising evidence from the audits and investigations and use the information to impact policy.
6 votesOFM is currently developing a comprehensive vulnerability tracking system with input from CPI. The system will capture significant issues from a variety of contractors to identify program vulnerabilities, including contractors that oversee the Medicare Advantage plans. CMS will then implement corrective action plans, which could include policy and/or operational improvements, to address the vulnerability.
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Cover nontraditional services that are demonstrated to reduce treatment cost and improve outcomes.
Many studies have shown that a simple course of hypnosis before surgery allows the patient to receive a lower dose of anesthesia and can greatly reduce recovery time. The same may be true of acupuncture treatments yet there is no method of Medicare or other third party payment for them, so they have not been widely used. There is clear evidence that these treatments work although the scientific mechanism through which they work isn’t well understood. I suggest that Medicare pay for hypnosis and acupuncture as incident to physician services under approved circumstances, such as before and after surgery.
6 votesReferred to the Employee Suggestion Program
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Pursue doctors who get incentives from drug companies for prescribing their drugs for antikickback
It’s widely known that pharmaceutical companies recruit the loyalty of doctors by offering them incentives, such as well paid faculty positions for seminars held at resort locations and other valuable benefits, with the understanding that the doctors will prescribe and promote the company’s drugs. There is little difference between those practices and compensation paid to a doctor for making referrals to a radiology clinic, a clear violation of anti-kickback laws. The result of the kickbacks in both situations is to siphon money from the healthcare system for the purpose of mutual enrichment of the participants in the arrangement without contributing…
5 votesThe Anti-Kickback Statute covers payments made to physicians by pharmaceutical companies to induce the prescriptions of their drugs. OIG investigates violations of the anti-kickback statute, regardless if the payment is made by a pharmaceutical company or a radiology clinic. OIG issued guidance in May 2003 titled “OIG Compliance program guidance for pharmaceutical manufacturers” that addresses these concerns.
CMS is implementing section 6002 of the ACA, often referred to as the “sunshine” provision that will require drug companies report a variety of payments they make to physicians. The increased transparency on payments is intended to reinforce the importance of maintaining proper and legal physician relationships with industry.
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CMS should pursue all overpayments regardless of the amount.
Too often CMS upper mgmt says that 1 million or 5 million dollar overpayments are too small to pursue. If CMS would make an effort to recover all overpayments, perhaps providers would be more cautious in submitting claims.
5 votesCMS agrees that all overpayments must be pursued. CMS collects all overpayments that have been calculated, that are greater than $100.
The commenter may have been referring to the development of cases that are believed to be small dollar value prior to the calculation of the overpayment. Resource constraints have historically been the driver of that approach. CMS, its contractors and law enforcement have prioritized their case load to go after high dollar value cases or instances where patient safety may be compromised.
CPI believes the new approaches to fraud detection being implemented through predictive analytics, as well as streamlining existing processes, will permit us to be able to take more actions in a shorter amount of time with the same amount of resources.
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