The Centers for Medicare & Medicaid Services will be outfitted with new fraud-fighting analytic tools designed to prevent wasteful and fraudulent payments in Medicare, Medicaid and the Children’s Health Insurance Program.

Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder said the tools would integrate many CMS pilot programs into the National Fraud Prevention Program and complement the work of the joint HHS and Department of Justice Health Care Fraud Prevention and Enforcement Action Team (HEAT).

Sebelius and Holder crisscrossed the country throughout 2010 bringing together federal, state and local partners, beneficiaries and providers to discuss innovative ways to eliminate fraud within the healthcare system.

“This has been a remarkable year for cracking down on healthcare fraud – and our success has been built on initiatives like these, combining the experience and insight of our law enforcement teams with new resources and cutting-edge technology,” said Sebelius while she and Holder were in Boston last December. “Thanks to the new tools and resources provided under the Affordable Care Act, we are more effective at going after the fraudsters that are stealing taxpayer dollars.”

“Here in Boston and in communities across the country, healthcare fraud schemes are being aggressively and permanently shut down," said Holder. "The District of Massachusetts, with U.S. Attorney Carmen Ortiz at its helm, has recovered more than $4 billion in civil and criminal healthcare fraud settlements over the past two years.”

"These actions are in large part because of the great work being led by Health Care Fraud Prevention and Enforcement Action Team," he added. "Through this initiative, we are working in partnership with government, law enforcement and industry leaders to protect taxpayer dollars, control healthcare costs and ensure the strength and integrity of our most essential healthcare programs. Simply put, we have taken our fight against healthcare fraud to a new level, and I am committed to continued collaboration, vigilance and progress.”

Not everyone is impressed with the anti-fraud efforts.

Sen. Charles Grassley (R-Iowa), ranking member of the Senate Finance Committee, is pressuring President Barack Obama's administration to defend how it has spent money fighting Medicare fraud. Grassley said he is concerned about "the stagnating number of criminal prosecutions" for healthcare fraud despite increased federal spending to fight fraud.

"I want to know why the Justice Department is having a tougher time putting people behind bars when we're giving them millions more to do the job," he said.

Predictive modeling

Banks, credit card companies, insurance and other consumer companies are using predictive modeling tools to identify potential fraud before it occurs. CMS officials said they are exploring similar systems to identify background information on potential fraud cases and links to questionable affiliations. This information will help CMS control who enrolls as healthcare providers or suppliers. Other tools will track billing patterns and other information to identify real-time aberrant trends that are indicative of fraud.

“Preventing fraud is more effective than the old ‘pay-and-chase’ model of fighting fraud after a sham provider has been paid and disappeared,” said CMS Administrator Donald Berwick, MD. “By using new predictive modeling analytic tools we are better able to expand our efforts to save the millions – and possibly billions – of dollars wasted on waste, fraud and abuse.”

CMS will use the results to take action before a claim is paid and is already taking administrative action to stop payments to “false fronts” in Texas, as identified through predictive modeling. CMS is also implementing an expanded authority, provided in the Affordable Care Act, to take such actions, including suspending payments when investigating a credible allegation of fraud.

“Using the most up-to-date technologies and adopting best practices across the nation’s healthcare system, we have a better chance of finding fraudulent and abusive providers before they even start billing Medicare or other health insurance,” said Peter Budetti, MD, director of CMS’ Center for Program Integrity.