Home Health & Hospice Week

Will the new number crunching put you in Medicare's crosshairs? Don't ever accuse CMS of being unsophisticated, at least from a software standpoint. Medicare Administrative Contractors have been using predictive analyses to scan your claims and potentially detect fraud, the Centers for Medicare & Medicaid Services says in MLN Matters article SE1133. "As of June 30, 2011, CMS is streaming all Medicare FFS claims through its predictive modeling technology," the article notes. "As each claim streams through the predictive modeling system, the system builds profiles of providers, networks, billing patterns, and beneficiary utilization. These profiles enable CMS to create risk scores to estimate the likelihood of fraud and flag potentially fraudulent claims and billing patterns." When the system alerts the MAC to unusual billing activity, the contractor will thoroughly review the claim before releasing payment to the provider. However, CMS notes, MACs will continue to use human analysts in concert [...]