The Centers for Medicare & Medicaid Services has an IT system—the Fraud Prevention System— that analyzes claims to identify health care providers with suspect billing patterns. Program integrity contractors get leads from the system to pursue fraud investigations.
GAO found that the system accounted for about 20 percent of CMS’s fraud investigations in fiscal years 2015 and 2016. It also helped the contractors identify leads and triage them faster (shown below).
The system also uses automated controls that identify payments associated with potential fraud and deny claims that violate Medicare rules or policies before the claims are paid.Read the full report