In July 2011, the Centers for Medicare and Medicaid Services (CMS) launched its new fraud prevention system (FPS), which was designed to use predictive modeling and data analytics to review all Medicare fee-for-service claims for indications of fraud.
Concerns about the FPS were first raised back in April of this year, when a mid-year report showed that the system had only prevented one bad claim, which totaled $7,951—despite the fact that the system cost $77 million. Then, in mid-October, two Senators took a tour of the new $3.6 million facility that housed the FPS, and expressed their concerns that after seeing a live demonstration of the FPS, there was “significant disconnect between the rhetorical claims made by the administration and the system’s actual current operational status,”
Consequently, Section 4241(e) of the Small Business Jobs Act of 2010 required CMS to issue a report on the FPS no later than three months after the program's first year of implementation , which two U.S. Senators calculated as October 1, 2012. Consequently, Bloomberg BNA reported that two U.S. Senate Finance Committee senators sent a letter to CMS Acting Administrator Marilyn Tavenner.
The letter, written Committee ranking member Orrin G. Hatch (R-Utah) and Sen. Tom Coburn (R-Okla.) said: “In the interest of being transparent to taxpayers and stakeholders, and accountable to Congress, we request you publicize the report and reply to our concerns about provider enrollment within three business days.” Hatch and Coburn said they were concerned the automated provider screening system, which was implemented in December 2011, has not been effective in weeding out fraud among Medicare providers.
Hatch and Coburn said they were also concerned that CMS has been sharing data on the FPS with the public but neglecting to keep Congress informed. “In fact, given the detailed statements by CMS staff in public speeches about the results of the FPS, it seems odd that specific details can be shared in public remarks yet you seek to keep the Congressional committee of jurisdiction in the dark,” the letter said.
Hatch and Coburn cited two examples from BNA's Health Care Fraud Report of CMS briefing the public on FPS information, including a presentation by David Nelson, director of CMS's Data Analytics and Control Group, at a September predictive analytics conference (16 HFRA 689, 9/19/12), and a speech by Peter Budetti, director of CMS's Center for Program Integrity, at America's Health Insurance Plans 2012 Medicare Conference (16 HFRA 752, 10/3/12).
One letter notes that the FPS “flagged a situation where 80% of a provider’s claims were for highly suspicious services.” As a result, CMS suspended the “provider’s payments, and eventually revoked Medicare billing privileges.” The Senators said this was “precisely the sort of information” they have been requesting for months now but have yet to receive.
This is the second letter from Hatch and Coburn seeking information from CMS on the FPS, following a July 31 inquiry. CMS responded on Aug. 27 that it would publish a report for Congress by the end of September (16 HFRA 690, 9/19/12).
“We had initially requested very detailed and specific information answering a number of questions regarding the metrics and costs of FPS and other related initiatives,” the senators said in their Oct. 15 letter. “Instead of a comprehensive response, we received a generic reply that was not truly responsive to our specific questions.” CMS stated in replies to the senators that it was “working diligently to finalize” their report.
Hatch and Coburn said they are still troubled by the lack of effective tools to measure the viability of the FPS, and said the delay in receiving the report raises questions about the reliability of CMS data.The Senators also expressed their concerns about CMS’ provider screening system, which was implemented in Decemeber 2011. The Senators noted that despite the screening of hundres of thousands of providers who are enrolled in Medicare, “numerous individuals continue to bill the Medicare program despite having been convicted of felonies or other offenses that should render them ineligible to do so.”