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Medicare Compliance & Reimbursement

Compliance:

Part B MACs Now Using 'Predictive Modeling' of Claims to Catch Fraud

Published on Sun Oct 17, 2010

Fortunately, software alone won't be responsible for nabbing claim issues. Don't ever accuse CMS of being unsophisticated, at least from a software standpoint. The agency announced last week that Part B MACs have been using predictive analyses to scan your claims and potentially detect fraud, according to 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 carrier will thoroughly review the claim before releasing payment to the practice. However, CMS notes, MACs will continue to use human analysts in concert with [...]
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