Data Analytics & Systems Group (DASG) Business Systems

The APS is an early detection screening, monitoring, and alerting tool which identifies bad actors before they can engage in fraud, waste, and abuse. This includes preventing ineligible providers from enrolling in Medicare, and determining which currently enrolled providers are ineligible so that CMS can take appropriate administrative action.

The API Gateway is a one-stop system where our program integrity partners can get information quickly from previously disparate systems by combining provider data from our systems into one view; creating a shortcut that allows qualified users to view the information from the systems in DASG in one place. It incorporates data from legacy systems, giving them new life and relevance. The tool provides a separate user view for law enforcement purposes—specifically designed to compare data from several systems used by our program integrity partners at once.

esMD is a secure system through which providers can voluntarily submit forms to the CMS review contractors for approval. By automating requests such as claims review and prior authorizations, esMD enhances interoperability, cost efficiency, and reduces administrative burdens for providers. This system supports both X12 and XDR file formats creating more accessibility to providers who may have limited resources or specific file needs. The types of documentation that esMD is able to process is constantly expanding to keep up with current needs.

The FPS offers predictive analytic technologies, including link- analysis and geo-mapping to detect and prevent fraud, waste, and abuse in accordance to the Small Business Jobs Act of 2010. Primarily used by CMS’ Unified Program Integrity Contractors (UPIC), FPS utilizes machine learning to effectively monitor and analyze Medicare fee for service (FFS) pre-paid claims. The FPS is seamlessly linked to the Unified Case Management for greater capture of the investigative process.

OnePI provides CMS’ program integrity partners with access to the Integrated Data Repository, as well as analytic tools necessary to identify improper payments and measure outcomes. The OnePI environment provides access to multiple analytical platforms including:

Providers use PECOS to enroll their NPI into the Medicare program, as well as to view, manage, and update their profile with CMS. Simultaneously, PECOS allows CMS and its stakeholders to continuously review, screen, and validate information, as well as monitor providers for adverse actions.

UCM is a centralized business workflow, data repository, and reporting system that creates a coordinated approach for managing pertinent fraud investigative data. Consolidating the efforts of CMS’ program integrity partners and stakeholders such as the UPICs, Medicare Administrative Contractors (MAC), and law enforcement, UCM provides a platform to share and coordinate information to efficiently address healthcare providers with credible allegations of fraud, waste, and abuse.