CMS' Fraud Prevention System — a tool designed to proactively identify fraudulent billing patterns before payments are made — has been delayed and will not be utilized before 2013, according to a report from the U.S. Government Accountability Office.
CMS implemented FPS in July 2011 as part of the Small Business Jobs Act. FPS analyzes Medicare claims to identify models of fraudulent behavior. It then alerts CMS to those claims and providers, which are then prioritized for program integrity reviews and investigations, as appropriate. This proactive approach differs from CMS' pay-and-chase fraud prevention efforts, in which the provider receives a payment that is later recouped by the government.
The GAO found that the tool has not yet been integrated with CMS' payment-processing system to prevent payments until the suspect claims are determined to be valid. The report said FPS' functionality has been delayed, as system requirements have taken more time. CMS estimates it will be implemented in January 2013, "but had not yet developed reliable schedules for completing this activity," according to the GAO report.
The report also found that "CMS has not yet defined or measured quantifiable benefits, or established appropriate performance goals" for FPS. CMS officials have also failed to conduct post-implementation reviews to determine whether FPS is effective in preventing the payment of fraudulent claims.
The GAO recommended that HHS Secretary Kathleen Sebelius direct CMS Administrator Marilyn Tavenner in defining the expected quantifiable benefits of FPS, establishing outcome-based performance targets, developing schedules to complete FPS integration with current claims processing systems and conducting a post-implementation review.
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CMS implemented FPS in July 2011 as part of the Small Business Jobs Act. FPS analyzes Medicare claims to identify models of fraudulent behavior. It then alerts CMS to those claims and providers, which are then prioritized for program integrity reviews and investigations, as appropriate. This proactive approach differs from CMS' pay-and-chase fraud prevention efforts, in which the provider receives a payment that is later recouped by the government.
The GAO found that the tool has not yet been integrated with CMS' payment-processing system to prevent payments until the suspect claims are determined to be valid. The report said FPS' functionality has been delayed, as system requirements have taken more time. CMS estimates it will be implemented in January 2013, "but had not yet developed reliable schedules for completing this activity," according to the GAO report.
The report also found that "CMS has not yet defined or measured quantifiable benefits, or established appropriate performance goals" for FPS. CMS officials have also failed to conduct post-implementation reviews to determine whether FPS is effective in preventing the payment of fraudulent claims.
The GAO recommended that HHS Secretary Kathleen Sebelius direct CMS Administrator Marilyn Tavenner in defining the expected quantifiable benefits of FPS, establishing outcome-based performance targets, developing schedules to complete FPS integration with current claims processing systems and conducting a post-implementation review.
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