CMS injects millions into anti-fraud command center, but will it work?

It's a $3.6 million facility. Equipped with a couple of dozen computer workstations, giant screens and new computerized detection systems, the facility will pull together some of the country's biggest experts in the government's campaign to fight fraud, the Associated Press reported. The problem is that Republicans aren't yet convinced the brand-spanking new facility aimed at curbing waste isn't a colossal waste of money, itself.

The Centers for Medicare & Medicaid Services yesterday announced the Program Integrity Commend Center in Baltimore to what it hopes will speed up anti-fraud efforts.

Senate Finance Committee members are demanding answers, accusing CMS of not being transparent. They wanted more details on the Fraud Prevention System (FPS) program and requested specific data regarding performance metrics, targeting of claims for review and actual program results.

"After our offices saw a live demonstration of the FPS, we have concluded there is a significant disconnect between the rhetorical claims made by the administration and the system's actual current operational status," U.S. Sens Orrin Hatch (R-Utah), Ranking Member of the Senate Finance Committee, and Committee member Tom Coburn (R-Okla.) wrote yesterday in a letter to CMS Acting Administrator Marilyn Tavenner.

Although CMS called the system "mature" and spent $77 million to procure the contract for FPS, Hatch and Coburn said "the number of predictive analytic algorithms, or 'models,' being applied to the live payment stream are underwhelming at best. CMS should have hundreds of models in operation, but instead there is a handful, and even the contract fulfillment only requires a few dozen."

The senators also noted that very few models were specifically designed to target procedures, services or supplies at high risk for fraud.

CMS, however, touted the new facility, which will bring together clinicians, data analysts, fraud investigators and policy experts in one physical space to "build and improve our sophisticated new predictive analytics that spot fraud, and to then move quickly on a lead, once potential fraud is identified," Peter Budetti, CMS deputy administrator and director of the Center for Program Integrity, said in a blog post yesterday. That coordination will help authorities move faster on investigations that usually take days or weeks to just hours, according to CMS.

"Our expectation is that this center will pay for itself many times over," Budetti said in the AP article.

Medicare currently loses an estimated $60 billion dollars each year to waste, fraud and abuse.

"This is unacceptable. The hemorrhaging of taxpayer dollars ... is ultimately a virtual invisible tax on taxpayers," Hatch and Coburn said.

Meanwhile, CMS noted it had the largest healthcare fraud busts in history, recovering a record $4 billion this year.

For more information:
- see the CMS blog post
- read the AP article
- here's the Senate Finance announcement and letter

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