CMS Urged to Overhaul Medicare Fraud Prevention
The Centers for Medicare & Medicaid Services (CMS) is facing a significant challenge with Medicare fraud, which costs taxpayers an estimated $60-$90 billion annually. To tackle this issue, CMS should move away from the reactive 'pay-and-chase' model and focus on prevention. The Fraud Prevention System (FPS), implemented in 2011, is a crucial tool in this fight, but it needs improvement.
Currently, only 5% of CMS's fraud investigations originate from FPS. To enhance its effectiveness, CMS should improve FPS's algorithms to detect more fraudulent claims and reduce false positives and negatives. The Government Accountability Office recommended in 2012 that CMS integrate FPS with Medicare's payment processing system to suspend payments for suspicious claims during investigations.
To drive progress, CMS should set clear performance targets and milestones to evaluate FPS's success in reducing fraud. Additionally, CMS could host a challenge, similar to those held by Netflix and the U.S. Defense Threat Reduction Agency, to improve FPS's fraud detection algorithms.
By integrating FPS with payment systems, improving its algorithms, and setting performance targets, CMS can significantly reduce Medicare fraud. These steps will help protect taxpayer money and ensure that Medicare funds are used effectively.
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