More Essential Data From CMS
Timothy Powell, CPA, CHCP
April 24, 2023
The Centers for Medicare & Medicaid Services (CMS) just keep putting out the data, and we want to keep you aware of both the data
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?
The Centers for Medicare & Medicaid Services (CMS) just keep putting out the data, and we want to keep you aware of both the data
Learn how providers can avoid falling into the trap of making clinically suspect diagnoses. The U.S. Department of Health and Human Services (HHS) Office of
Please log in to your account to comment on this article.
Struggling with ICD-10-CM coding for diabetes and complications? This expert-led webcast clarifies complex combination codes, documentation gaps, and sequencing rules to reduce denials and ensure compliance. Dr. Angela Comfort will provide actionable strategies to accurately link diabetes to complications, improve provider documentation, and optimize reimbursement—helping coders, CDI specialists, and HIM leaders minimize audit risks and strengthen revenue integrity. Don’t miss this chance to master diabetes coding with real-world case studies, key takeaways, and live Q&A!
Uncover critical guidance. Kay Piper provides an interactive review on coding guidelines and more in the AHA’s fourth quarter 2025 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Uncover critical guidance. Kay Piper provides an interactive review on coding guidelines and more in the AHA’s third quarter 2025 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Uncover critical guidance. Kay Piper provides an interactive review on coding guidelines and more in the AHA’s second quarter 2025 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Struggling with CMS’s 3-Day Payment Window? Join compliance expert Michael G. Calahan, PA, MBA, CCO, to master billing restrictions for pre-admission and inter-facility services. Learn how to avoid audit risks, optimize revenue cycle workflows, and ensure compliance across departments. Critical for C-suite leaders, providers, coders, revenue cycle teams, and compliance teams—this webcast delivers actionable strategies to protect reimbursements and meet federal regulations.
Providers face increasing Medicare audits when using skin substitute grafts, leaving many unprepared for claim denials and financial liabilities. Join veteran healthcare attorney Andrew B. Wachler, Esq., in this essential webcast and master the Medicare audit process, learn best practices for compliant billing and documentation, and mitigate fraud and abuse risks. With actionable insights and a live Q&A session, you’ll gain the tools to defend your practice and ensure compliance in this rapidly evolving landscape.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
Copyright © 2025 ICD10monitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
