Inside CMS’ war room

The bat­tle against fraud comes un­der scru­tiny

Modern Healthcare - - THE WEEK IN HEALTHCARE -

Health­care fraud is big busi­ness, and so is the bat­tle to stop it. Crit­ics, how­ever, want bet­ter an­swers from the Obama ad­min­is­tra­tion about how it is spend­ing fed­eral funds in the fight against the es­ti­mated $60 bil­lion lost to fraud, waste and abuse in fed­eral health­care pro­grams an­nu­ally.

Last week, the fed­eral gov­ern­ment’s new health­care-fraud-fight­ing con­sor­tium, the Cen­ter for Pro­gram In­tegrity, for­mally opened its new $3.6 mil­lion com­mand cen­ter in an uniden­ti­fied of­fice park in the Bal­ti­more metro area. Im­ages from inside the fraud nerve cen­ter de­pict a ring of work sta­tions sur­round­ing a mas­sive war room-style dig­i­tal screen dis­play­ing data trends.

The new CMS Pro­gram In­tegrity Com­mand Cen­ter is home to hun­dreds of work­ers as well as the new $77 mil­lion pre­dic­tive an­a­lyt­ics pro­gram that is scan­ning 4.5 mil­lion Medi­care feefor-ser­vice claims a day look­ing for sus­pi­cious pat­terns, us­ing the same tech­niques as credit card com­pa­nies scan­ning their fi­nan­cial net­works for fraud­u­lent charges.

The cen­ter houses hun­dreds of fraud-fight­ing em­ploy­ees from Medi­care, Med­i­caid, HHS’ in­spec­tor gen­eral’s of­fice and the FBI, along with in­ves­ti­ga­tors from lo­cal law en­force­ment and the pri­vate zone pro­gram in­tegrity Con­trac­tors, all of whom will work leads gleaned from the dig­i­tal tools in real time.

“The re­sult is that in­ves­ti­ga­tions that used to take days and weeks can now be done in a mat­ter of hours,” Dr. Peter Budetti, di­rec­tor of the pro­gram in­tegrity cen­ter, wrote in a CMS blog post. “And this new tech­nol­ogy can help de­tect and pre­vent po­ten­tial prob­lems and pay­ments. That can mean mil­lions of tax­payer dol­lars stay­ing out of the hands of fraud­sters.”

How­ever, two mem­bers of the Se­nate Fi­nance Com­mit­tee—rank­ing mem­ber Or­rin Hatch (R-Utah) and Tom Coburn (R-Okla.)— are ask­ing some pointed ques­tions about whether it’s money well-spent.

In a July 31 let­ter de­mand­ing an­swers from the CMS, the sen­a­tors said their con­cern was mo­ti­vated by a lack of ac­count­abil­ity on CMS’ part to show whether the year-old pre­dic­tive mod­el­ing pro­gram, known as the Fraud Preven­tion Sys­tem, has been suc­cess­ful.

“For some time, we have heard a grow­ing cho­rus of con­cerns from a wide range of cred­i­ble en­ti­ties who have ex­pressed con­cerns about FPS,” the sen­a­tors wrote.

The pub­lic has re­ceived dif­fer­ing mes­sages about the per­for­mance of the sys­tem, which was man­dated in the Small Busi­ness Jobs Act of 2010 and de­signed through a con­tract with de­fense firm Northrop Grum­man.

The As­so­ci­ated Press re­ported in Fe­bru­ary that the sys­tem had pre­vented only one sus­pi­cious pay­ment by the end of 2011, for $7,591.

In their July 31 let­ter, Hatch and Coburn said the CMS had not yet used the sys­tem to stop any claims be­fore they were paid.

Yet in an April 4 e-mail to Mod­ern Health­care, an HHS spokesman said more than $30 mil­lion in im­proper pay­ments had been stopped, pre­vented or iden­ti­fied. That in­cluded $9 mil­lion in cases re­ferred to law en­force­ment, $2.2 mil­lion in over­pay­ment de­ter­mi­na­tions and $1.5 mil­lion saved through pre-pay­ment and auto-deny pro­grams.

“We un­der­stood from the be­gin­ning that pre­dic­tive mod­el­ing would not reach its full po­ten­tial in a day, but would evolve into the most ef­fec­tive tool for pre­vent­ing fraud in his­tory,” the HHS of­fi­cial said in the e-mail.

The CMS an­nounced in a May 11 con­tract-doc­u­ment form that the sys­tem “will be­come ma­ture” in June 2012.

Asked for more up-to-date in­for­ma­tion last week, CMS spokesman Brian Cook wrote in an e-mail that the Small Busi­ness Act re­quired the agency to cer­tify its per­for­mance num­bers with HHS’ in­spec­tor gen­eral’s of­fice, and that it plans to re­lease those fig­ures to Congress this fall. He de­clined to re­lease pre­lim­i­nary es­ti­mates.

Coburn and Hatch crit­i­cized the CMS’ lack of trans­parency or con­crete goals, es­pe­cially since the agency was spend­ing money on such lofty projects as the large Com­mand Cen­ter com­puter screen while not im­ple­ment­ing cheaper rec­om­men­da­tions to fight fraud.

The 2011 Com­pen­dium of Unim­ple­mented Rec­om­men­da­tions from the in­spec­tor gen­eral’s of­fice lists 22 ideas that in­ves­ti­ga­tors say could save Medi­care money, but which have not been fully im­ple­mented by the staff. The 2012 re­port is due this year.

CMS act­ing Ad­min­is­tra­tor Mar­i­lyn Taven­ner said in a Feb. 7 let­ter that the agency is al­ready work­ing to ad­dress many ideas put for­ward by HHS’ in­spec­tor gen­eral, but that any on­go­ing ef­forts are not for­mally con­sid­ered “im­ple­mented” by the in­spec­tor gen­eral’s of­fice.

Hatch and Coburn also ques­tioned the July 26 an­nounce­ment that the CMS was part­ner­ing with a half-dozen pri­vate in­sur­ers to pre­vent billing fraud.

The pro­gram is de­signed to share in­for­ma­tion among pub­lic and pri­vate pay­ers on fraud schemes, vul­ner­a­ble billing codes and ge­o­graphic hot spots.

The sen­a­tors said it was not clear, how­ever, what or­ga­ni­za­tions will be shar­ing health in­for­ma­tion on what sys­tems, and which “con­trac­tor or trusted third party” would be con­duct­ing the anal­y­sis.

Joe Carl­son

The fraud com­mand cen­ter, shown in a video the agency pro­vided, in­cludes a $77 mil­lion pre­dic­tive an­a­lyt­ics pro­gram that can scan 4.5 mil­lion fee-for-ser­vice claims a day.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.