tci Medicare Compliance & Reimbursement - 2016 Issue 12

3 Examples: FPS 'Big Data' Can Spot Fraudulent Medicare Claims

Predictive analytics spot over-billing and more, leading to revocation. With crystal ball-like abilities, the Centers for Medicare & Medicaid Services (CMS) is catching improper payments before it even sends them to you. Here are a few of the cases that the Fraud Prevention System (FPS) has identified: Services not rendered: The FPS’s “big data” and predictive analytics identified a Florida home health agency that billed for services that it never rendered. CMS placed the agency on prepayment review and payment suspension, and then referred the agency to law enforcement and revoked its Medicare enrollment. Non-covered services: The...

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