BC Advantage - 2018 Issue 3

The Comprehensive Error Rate Testing Program

With nearly a million physicians in this country, how do auditing organizations determine whom to audit? As of 2011, 100% of all Medicare fee-for-service claims are passed through the Fraud Prevention System, a series of predictive analytics algorithms that help to identify claims that may be have been billed incorrectly. While those results can help to target particularly high risk providers, there is much more to the audit/don't audit decision than just risk. For most auditors, because they are private contractors, their remuneration, bonuses, or contract continuation are tied to results-and make no mistake, results are measured in dollars...

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