Is the Fraud Prevention System Working?


While everyone in Washington is committed to stopping Medicare fraud, it seems not everyone is on the same page about how to do it. A recent letter from some senior Republicans questioned whether the Centers for Medicare & Medicaid Services is taking full advantage of predictive analytics to stop improper payments from going out the door in the first place.

Republicans raised concerns that CMS is still stuck in a “pay and chase” model, tracking down improper payments after they’ve been made. While the CMS Fraud Prevention System is designed to use predictive analytics and data analysis to stop improper payments from ever being made, Republicans said they’re concerned it’s not being used properly.

The FPS was rolled out in 2011 and was responsible for $133 million in adjusted savings in 2014, according to the most recent certification of the program by the Health and Human Services Office of Inspector General.

Arnold & Porter’s Kirk Ogrosky told me that most of the Department of Justice’s fraud cases over the last five years have been the result of pay and chase methods, not predictive analytics. “While there is no question that CMS and DOJ are getting better, it appears to be a slow-moving, bureaucratically burdened train,” Ogrosky told me.

The Republicans’ letter asked for a list of all the Medicare fraud schemes that have been referred to Zone Program Integrity Contractors (ZPICs) by the FPS for further investigation, as well as how many total investigations ZPICs have conducted over the past three years. Responses were requested by Sept. 26.

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