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Diane Publishing Books
Medicare Fraud Prevention: CMS has Implemented a Predictive Analytics System, but Needs to Define Measures to Determine Its Effectiveness
Valerie C. Melvin (au); Kathleen M. King (au)
GAO has designated Medicare as a high-risk program, in part because its complexity makes it particularly vulnerable to fraud. The Centers for Medicare and Medicaid Services (CMS), as the agency within the Dept. of Health and Human Services (HHS) responsible for administering Medicare and reducing fraud, uses a variety of systems that are intended to identity fraudulent payments. To enhance these efforts, the Small Business Jobs Act of 2010 provided funds for and required CMS to implement predictive analytics technologies --automated systems and tools that can help identify fraudulent claims before they are paid. In turn, CMS developed its Fraud Prevention System (FPS). This report (1) determines the status of the implementation and use of FPS; (2) describes how the agency uses FPS to identify and investigate potentially fraudulent payments; (3) assesses how the agencyäó»s use of FPS compares to private insurersäó» and Medicaid programsäó»practices; and (4) determines the extent to which CMS has defined and measured benefits and performance goals for the system. Tables and figures. This is a print on demand report.
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