decisionhealth Newsletters, Part B News - 2011 Issue 7 (July)
CMS has new way to target claims
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Article Overview
This article explains CMS’s launch of a predictive modeling approach designed to help identify suspicious Medicare claims before they are paid. It discusses the broader anti-fraud and program integrity context, the use of risk scoring and real-time data analysis, and the roles of CMS, its Center for Program Integrity, a federal contractor, and the Office of Inspector General. The piece is relevant to professionals who follow Medicare program integrity, claims review, and fraud prevention policy.
Why This Topic Matters
Changes in CMS fraud-detection strategy can affect how Medicare claims are screened, prioritized, and reviewed. Understanding this initiative helps coding, billing, compliance, and reimbursement stakeholders stay informed about evolving program integrity efforts.
What You Will Learn
- How CMS describes its predictive modeling initiative for Medicare claims review.
- What broad types of data analysis are used to identify potentially suspicious claims.
- Which organizations are involved in the fraud-detection and follow-up process.
- How the initiative fits into broader Medicare program integrity efforts.
Who Should Read This
- Medical coders
- Billing specialists
- Compliance professionals
- Revenue cycle staff
- Healthcare administrators
- Medicare policy analysts
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