CMS to deploy predictive model to cut Medicare fraud

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The Centers for Medicare & Medicaid Services (CMS) has announced that starting July 1, it will begin using predictive modeling technology from Nothrop Grumman, a provider of advanced information tools, 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 helps stop fraudulent claims before they are paid, CMS stated. The initiative builds on the anti-fraud tools and resources provided by the Patient Protection & Affordable Care Act.

Northrop Grumman was 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, a Verizon company, to leverage claims data and its information to fight healthcare fraud, according to CMS.

Northrop Grumman will deploy algorithms and an analytical process that looks at CMS claims—by beneficiary, provider, service origin or other patterns—to identify potential problems and assign an “alert” and assign “risk scores” for those claims.

These problem alerts will be further reviewed to allow CMS to both prioritize claims for additional review and assess the need for investigative or other enforcement actions, CMS added.