CMS has fallen behind on its schedule for implementing a $90 million predictive-modeling system to fight Medicare and Medicaid fraud, according to a report from the Government Accountability Office, Modern Healthcare reports.
Background
The new CMS Fraud Prevention System is designed to use predictive analytic models to evaluate Medicare fee-for-service data and identify high-risk claims and health care providers.
The technology aims to help federal officials find suspicious claims and immediately stop payments before they are sent.
GAO started investigating the fraud prevention system after GOP senators said that their questions about the system's implementation had been ignored. The senators also said that the system missed a July start date and will not begin full operations until January 2013 or later (Daly, Modern Healthcare, 11/15).
GAO's Findings
The GAO report found that many details about CMS' transition to the new fraud prevention system remain unclear. The report stated, "CMS has not yet defined or measured quantifiable benefits, or established appropriate performance goals."
In addition, the fraud prevention system has yet to be fully incorporated with CMS' payment processing system, the report found (Millman, "Pulse," Politico, 11/16).
According to GAO, CMS estimated that the fraud prevention system would be fully implemented by January 2013 but the agency has "not yet developed reliable schedules for completing this activity" (Modern Healthcare, 11/15).
Recommendations
GAO recommended that CMS:
- Develop a schedule for integrating the anti-fraud and payment processing systems;
- Determine quantifiable benefits, performance targets and milestones for the fraud reporting system and relay such information to Congress; and
- Conduct a review of the anti-fraud system after it is implemented ("Pulse," Politico, 11/16).