Outpatient Facility Coding Alert - 2016 Issue 12
3 Examples: FPS 'Big Data' Can Spot Fraudulent Medicare Claims
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Article Overview
This article explains how CMS’s Fraud Prevention System (FPS) uses predictive analytics to identify potentially improper Medicare claims and trigger follow-up actions. It is relevant to providers, billing staff, compliance teams, and auditors who want a high-level view of program integrity monitoring, fraud detection, and enrollment enforcement involving Medicare claims.
Why This Topic Matters
Understanding how CMS identifies questionable billing activity helps organizations recognize the compliance focus areas that can lead to review, suspension, referral, or enrollment revocation.
What You Will Learn
- How CMS uses analytics to identify potentially improper Medicare billing patterns
- What kinds of claim behaviors may attract program integrity scrutiny
- How enforcement actions can follow FPS identification of suspicious activity
- Why Medicare compliance and documentation integrity matter to providers and billing teams
Who Should Read This
- Physicians
- Hospitals and health systems
- Home health agencies
- Ambulance suppliers
- Medical clinic administrators
- Medical coders
- Medical billers
- Compliance officers
- Revenue cycle professionals
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