The House Committee on Ways & Means' Subcommittee on Oversight held a March 24 hearing on “The Use of Data to Stop Medicare Fraud.” The hearing was an opportunity to review the federal government’s use of data analysis, and particularly the Centers for Medicare & Medicaid Services (CMS) Fraud Prevention System (FPS), which is used to identify emerging trends and stop Medicare fraud.

Shantanu Agrawal, MD, the CMS Deputy Administrator & Director of CMS’ Center for Program Integrity, was a witness for the hearing. CMS’ written testimony highlights that the agency is continuously working to refine and improve program integrity efforts in the Medicare and Medicaid programs. The President’s FY 2016 Budget includes 16 legislative proposals that provide additional tools to further enhance program integrity efforts in the Medicare and Medicaid programs. Additionally, the testimony notes, “Since 2011, CMS has been using its FPS to apply advanced analytics on all Medicare fee-for-service claims on a streaming, national basis by using predictive algorithms and other sophisticated analytics to analyze every Medicare fee-for-service claim against billing patterns. The system also incorporates other data sources, including information on compromised Medicare cards and complaints made through 1-900-MEDICARE. The FPS is also an important management tool, as it prioritizes leads for ZPICs in their designated region, making program integrity strategy more data-driven.”

During the hearing, Chairman Peter Roskam (R-IL) shared that the FPS was able to save Medicare $54 million in its second year of operation and the program is still detecting less than 1 percent of Medicare improper payments. Furthermore, it was noted that the Medicare program has accounted for $60 billion in improper payments last year, and had an error rate of 12.7 percent.

Dr. Agrawal noted, “Improper documentation was a major driver of the improper error rate, especially among home health-care providers. For example, improper claims can occur when the required face-to-face meeting between a provider and a patient prior to the provision of home-health services is not properly documented.”

Chairman Roskam and several subcommittee members called for improved interagency cooperation on anti-fraud efforts.