At a Boston fraud-prevention summit, the Obama administration announced a plan to use predictive-modeling software to fight Medicare and Medicaid fraud.
Taking a tip from banks, credit card firms and insurance
companies, CMS (the Centers for Medicare and Medicaid Services) will implement
predictive-modeling software to fight fraudulent claims for Medicare and
Medicaid and the Children's Health Insurance program.
U.S. Department of Health and Human Services Secretary Kathleen
Sebelius and Attorney General Eric Holder made the announcement at a health
care fraud-prevention summit at the University
of Massachusetts on Dec. 16.
"Simply put, we have taken our fight against health
case fraud to a new level, and I am committed to continued collaboration,
vigilance and progress," Attorney General Eric Holder said in a statement.
Predictive-modeling applications use analytics to create
statistics on future behavior and trends. Companies that offer these tools
, Oracle, SAP and StatSoft.
CMS, an agency of HSS (Department of Health and Human
Services), is currently seeking bidders from interested software vendors,
according to Peter Ashkenaz, a spokesperson for CMS. Contracts will follow.
"We issued a solicitation asking the companies to bid
on software programs, so at this point there is no specific program that we've
identified," Ashkenaz told eWEEK.
Predictive-modeling tools will prevent fraudulent health
care providers from invading the system and be able to track suspicious
billing, affiliations and financial trends. The programs rely on past
information about an individual or company to identify fraudulent activity, CMS
"By using new predictive-modeling analytic tools, we
are better able to expand our efforts to save the millions-and possibly
billions-of dollars wasted on waste, fraud and abuse," CMS Administrator
Dr. Donald Berwick said in a statement.
The new analytic tools will support the efforts of the HHS and HEAT
(Department of Justice Health Care Fraud Prevention and Enforcement Action
CMS has already used predictive modeling tools to halt payments to
"false fronts" in Texas,
according to the agency.
Another example involves a partnership between CMS and RATB (Federal
Recovery Accountability and Transparency Board) to uncover high-risk providers. The
effort spotted suspect providers by combing public data and relying on fraud
alerts from courts and health care payers.
"Using the most up-to-date technologies and adopting best practices
across the nation's health care system, we have a better chance of finding
fraudulent and abusive providers before they even start billing Medicare or
other health insurance," Dr. Peter Budetti, director of CMS' Center
for Program Integrity, said in a statement.
The Boston meeting was part of a series of fraud-prevention summits announced by President
Obama on June 8.
Obama had formed a Financial
Fraud Enforcement Task Force
in November 2009 to respond to the struggling
economy and an increase in fraud.
"This has been a remarkable year for cracking down on health care fraud-and
our success has been built on initiatives like these, combining the experience
and insight of our law enforcement teams with new resources and cutting-edge
technology," Sebelius said in a statement. "Thanks to the new tools
and resources provided under the Affordable Care Act, we are more effective at
going after the fraudsters that are stealing taxpayer dollars."