Business Intelligence and Fraud

Why doesn’t CMS use business intelligence to catch fraud?

You can call it business intelligence. You can call it common sense. As Medicare pays fee-for-service (FFS) claims through its Medicare Administrative Contractors (MACs), it compiles reports of the paid claims by provider. 

The Centers for Medicare & Medicaid Services (CMS) knows the number of claims paid by each provider and the HCPCS codes that were listed on the claims. They have the data to determine how many physicians bill their claims at the highest possible levels for evaluation and management (E&M) services.

Medicare Advantage (MA) plans regularly submit paid claims data to CMS. In determining the risk adjustment scores of such plans, CMS uses this data to adjust payments to them. 

My question is this: why doesn’t CMS use business intelligence to catch such issues, before it turns into massive cases of fraud? CMS has the data to see spikes in payments to individual providers. 

It begs the question: how do bad actors submit claims for months or years that should have been caught in the first month?  

Years ago, almost all the physicians in the top 20 of Medicare payment recipients were ophthalmologists. It turned out that Medicare was paying very high rates for interocular lenses. A number of these physicians were eventually charged with fraud. 

Just a few years later, in 2019, a New York ophthalmologist was in the news when he was convicted of Medicare fraud for billing millions of dollars in operations that were never performed over a 10-year period.

My question is, why is it that this fraud can’t be investigated in real time, based on trending data?  Why can’t Medicare use data analytics to find anomalous payment data and investigate early? 


Timothy Powell, CPA

Timothy Powell is a nationally recognized expert on regulatory matters, including the False Claims Act, Zone Program Integrity Contractor (ZPIC) audits, and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) compliance. He is a member of the RACmonitor editorial board and a national correspondent for Monitor Mondays.

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