Business Intelligence and Fraud

Why doesn’t CMS use business intelligence to catch fraud?

You can call it business intelligence. You can call it common sense. As Medicare pays fee-for-service (FFS) claims through its Medicare Administrative Contractors (MACs), it compiles reports of the paid claims by provider. 

The Centers for Medicare & Medicaid Services (CMS) knows the number of claims paid by each provider and the HCPCS codes that were listed on the claims. They have the data to determine how many physicians bill their claims at the highest possible levels for evaluation and management (E&M) services.

Medicare Advantage (MA) plans regularly submit paid claims data to CMS. In determining the risk adjustment scores of such plans, CMS uses this data to adjust payments to them. 

My question is this: why doesn’t CMS use business intelligence to catch such issues, before it turns into massive cases of fraud? CMS has the data to see spikes in payments to individual providers. 

It begs the question: how do bad actors submit claims for months or years that should have been caught in the first month?  

Years ago, almost all the physicians in the top 20 of Medicare payment recipients were ophthalmologists. It turned out that Medicare was paying very high rates for interocular lenses. A number of these physicians were eventually charged with fraud. 

Just a few years later, in 2019, a New York ophthalmologist was in the news when he was convicted of Medicare fraud for billing millions of dollars in operations that were never performed over a 10-year period.

My question is, why is it that this fraud can’t be investigated in real time, based on trending data?  Why can’t Medicare use data analytics to find anomalous payment data and investigate early? 

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Timothy Powell, CPA, CHCP

Timothy Powell is a nationally recognized expert on regulatory matters, including the False Claims Act, Zone Program Integrity Contractor (ZPIC) audits, and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) compliance. He is a member of the RACmonitor editorial board and a national correspondent for Monitor Mondays.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →