GAO assesses fraud prevention system for Centers for Medicare & Medicaid Services

The Government Accountability Office (GAO) said the Centers for Medicare & Medicaid Services (CMS) Fraud Prevention System accounted for 20 percent of fraud investigations in 2015 and 2016.

In its assessment, GAO officials said the system, which analyzes claims to identify healthcare providers with suspect billing patterns, also uses automated controls that identify payments associated with potential fraud and denies claims that violate Medicare rules or policies before the claims are paid.

The GAO report referenced investigations initiated or supported by the Fraud Prevention System (FPS) led to corrective actions against providers and generated savings. During fiscal year 2016, CMS reported that 90 providers had their payments suspended because of investigations initiated or supported by FPS resulting
in an estimated $6.7 million in savings.

After conversations with officials representing Medicare’s program integrity contractors, the GAO learned the FPS helps speed up certain investigation processes, such as identifying and triaging suspect providers for investigation. Once an investigation is initiated, however, the FPS has generally not sped up the process for investigating and gathering evidence against suspect providers.

GAO officials said as part of its assessment, the agency interviewed CMS officials and CMS program integrity contractors regarding how they use the FPS, and a non-generalizable selection of Healthcare Fraud Prevention Partnership participants regarding information, data sharing practices and anti-fraud collaboration efforts.