Corporate Compliance

Sebelius and Holder seek new tools to prevent and fight fraud

Compliance Monitor, December 22, 2010

CMS is looking to acquire new state-of-the-art fraud fighting tools to prevent wasteful and fraudulent payments in federal healthcare programs, according to a Department of Health and Human Services press release.

U.S. Department of Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder announced that CMS is soliciting fraud fighting analytic tools to help the agency during the fourth regional health care fraud prevention summit in Boston.

CMS is exploring using predictive modeling tools to identify background information on potential fraudulent actors and create links to questionable affiliations. This information will help prevent people from enrolling as healthcare providers or suppliers for the sole purpose of defrauding the health care system. Other tools will track billing patterns and other information to identify real-time fraud trends.

CMS hopes to use the tools to take prevent fraud before a claim is paid. CMS is already starting to take administrative action to stop payments to “false fronts” in Texas identified through predictive modeling. The Affordable Care Act also expands CMS’s ability to fight fraud, including suspending payments when investigating a credible allegation of fraud.

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