CMS Uses Predictive Modeling to Help Fight Medicare Fraud

Nov. 16, 2011
On the heels of the White House launch of the Campaign to Cut Waste—an administration wide initiative to crack down on waste, fraud and abuse, the

On the heels of the White House launch of the Campaign to Cut Waste—an administration wide initiative to crack down on waste, fraud and abuse, the Centers for Medicare & Medicaid Services (CMS) announced that starting July 1, it will begin using innovative predictive modeling technology to fight Medicare fraud. Similar to technology used by credit card companies, predictive modeling helps identify potentially fraudulent Medicare claims on a nationwide basis, and help stop fraudulent claims before they are paid. This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made.

Original Medicare claims will be analyzed using innovative risk scoring technology that applies effective predictive models, an approach similar to that used by the private sector to successfully identify fraud. For the first time, CMS will have the ability to use real-time data to spot suspect claims and providers and take action to stop fraudulent payments before they are paid.

The London-based Northrop Grumman, a global provider of advanced information solutions, has been selected through a competitive procurement to develop CMS’ national predictive model technology format using best practices of both public and private stakeholders. Northrop Grumman has partnered with National Government Services (NGS) and Federal Network Systems, LLC, a Verizon company (FNS), to leverage the wealth of claims data and its information to fight health care fraud. CMS used industry guidance, innovative ideas from private and provider entities and related data in developing the scope of work for this national fraud prevention program. Given the importance of this contract to CMS’ overall anti-fraud efforts, this contract is being implemented nationally and ahead of schedule.


Sponsored Recommendations

Trailblazing Technologies: Looking at the Top Technologies for the Emerging U.S. Healthcare System

Register for the first session of the Healthcare Innovation Spotlight Series today to learn more about 'Healthcare's New Promise: Generative AI', the latest technology that is...

Data: The Bedrock of Digital Engagement

Join us on March 21st to discover how data serves as the cornerstone of digital engagement in healthcare. Learn from Frederick Health's transformative journey and gain practical...

Northeast Georgia Health System: Scaling Digital Transformation in a Competitive Market

Find out how Northeast Georgia Health System (NGHS) enabled digital access to achieve new patient acquisition goals in Georgia's highly competitive healthcare market.

2023 Care Access Benchmark Report for Healthcare Organizations

To manage growing consumer expectations and shrinking staff resources, forward-thinking healthcare organizations have adopted digital strategies, but recent research shows that...