Former CMS administrator says fraud detection is better, but gaps remain

The transition from a reactive approach to relying on claims data to better predict and prevent fraudulent payments has led to significant progress in fighting Medicare and Medicaid fraud, former Centers for Medicare & Medicaid Services (CMS) Administrator Don Berwick told the Journal for the American Medical Association (JAMA).

Berwick (pictured right), who served as the CMS Administrator from July 2010 to December 2011, says the agency began the shift toward predictive analytics under his leadership. That transition continued even after his tenure, which has led to a greater degree of enforcement actions and criminal prosecution.  

Last November, CMS announced that it created an Office of Enterprise Data and Analytics in order to analyze claims data in real time. Recently, CMS announced that its Fraud Prevention System had "identified or prevented" $454 million in fraudulent claims in 2014, although the Office of Inspector General (OIG) estimated the number was closer to $133 million.

Berwick added that self-regulation among doctors and nurses could have an even greater impact in detecting potential schemes.

"I think the vast majority of doctors and nurses and pharmacists and others who are out there trying to do a good job, they've got to be part of the detection apparatus that allows us to spot the criminals early on and intervene before they've done too much damage," he told JAMA.

However, Berwick balked at the idea that a value-based payment system (as opposed to fee-for-service reimbursement) will help reduce Medicare fraud. He argued that physicians should help patients identify potential fraud, but value-based compensation may not be the best incentive to facilitate that discussion.

Medicare and Medicaid have faced relentless scrutiny over the years concerning fraud prevention. This year, the Government Accountability Office estimated the two programs accounted for more than $75 billion in improper payments in 2013. Last month, a retiring special agent for the OIG said that Medicare fraud enforcement has improved over the years because of predictive analytics, but concerns still remain with organized crime rings and Part D payments for addictive opioids.

For more:
- read the JAMA interview

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