To make rapid, accurate payment decisions and identify fraud as it happens, data and analytics are needed. CMS is investing in data systems and initiatives so that this information can be analyzed and shared.
Fraud Prevention System
We use the Fraud Prevention System (FPS) to identify, at the time of claim submission, when mistakes or intentional behavior may lead to improper payments or indicate fraud. The next generation of CMS' FPS, launched in February 2017, aggressively expands our capabilities of preventing improper payments. CMS estimates that this cutting-edge system will result in a 20 percent savings increase over the substantial returns already realized by the use of predictive analytics in the claims processing system. You can read about the FPS return on investment (ROI) in this 2015 Report to Congress.
Healthcare Fraud Prevention Partnership
The Healthcare Fraud Prevention Partnership (HFPP) is a voluntary, public-private partnership between the Federal Government, state and local agencies, law enforcement, private health insurance plans, employer organizations, and healthcare anti-fraud associations to identify and reduce fraud, waste, and abuse across the healthcare sector. The HFPP has strategically positioned itself as a leading body of empowerment to reduce fraud across the healthcare industry by providing an unparalleled cross-payer data source and generating real-time, comprehensive approaches.
Provider Enrollment Systems
Provider Enrollment systems are key to keeping problematic providers out of our programs. The National Plan & Provider Enumeration System (NPPES) was created as a central system for National Provider ldentifier. Our Advanced Provider Screening System continually pulls information from multiple sources to check the eligibility of providers. With public input, CMS is also rethinking and improving our provider enrollment system (PECOS) to be more intuitive and user-friendly. Improvements will focus on reducing provider administrative work, improving operational efficiency, and strengthening screening.
Unified Program Integrity Contractors
To consolidate efforts and resources used in investigating payments, CMS is transitioning to Unified Program lntegrity Contractors. This will result in the need for less contract support as we move to a centralized system.
Program Integrity Modeling & Analytics
Program lntegrity modeling and analytics are key to using our systems and technology to identify and prevent improper payments. For example, the National Correct Coding lnitiative promotes consistent coding across Medicare and Medicaid, preventing avoidable improper payments due to coding errors.
Medicare Parts C&D Plan Integrity
Many of our beneficiaries receive their Medicare benefits through the support of our private plan partners. We aim to support the integrity of Medicare Advantage (MA) and Part D prescription drug plans using predictive analytics and business intelligence tools to identify fraud, waste and abuse and to ensure that these plans receive accurate payments from CMS.