It’s true that Medicare and Medicaid provide vital, lifesaving services for seniors and low-income individuals and families. It is equally true that Medicare and Medicaid fraud costs taxpayers millions of dollars each year. In order to keep Medicaid services under check and prevent fraud, the U.S. Department of Health & Human Services conducts annual oversight reviews of the Centers for Medicare & Medicaid Services (CMS) to help identify and prosecute fraud. However, in 2017, Department of Health & Human Services Office of Inspector General (OIG) discovered that CMS could be doing more to prevent fraud.
According to the OIG, the department conducted a required audit to certify the actual and projected savings and the return on investment related to the use of the Fraud Prevention System (FPS), which uses models that predict suspicious behavior to identify and prevent the payment of improper Medicare claims.
A recent report from the Government Accountability Office found that the FPS helped prevent billions of dollars in improper payments. FPS analyzes Medicare and Medicaid claims to identify health care providers whose billing practices are suspect, and tag them for further investigation.
During their audit, however, OIG discovered that the Department of Health and Human Services might not have the capability to trace the savings from administrative actions back to the specific FPS model that generated the savings. Without this capability, the Department is not able to accurately evaluate an individual FPS model’s performance. Therefore, the Department may be limited in how it assesses the effectiveness of its predictive analytics technologies.
What does OIG recommend?
To correct this issue, the OIG recommends that CMS make better use of its performance results to refine and enhance the predictive analytics technologies of the FPS models by ensuring that:
- the redesigned FPS is effective in allowing CMS to track savings from administrative actions back to individual FPS models,
- contractors adjust savings reported to CMS to reflect only FPS-related savings amounts, and
- evaluations of FPS model performance consider not only the identified savings but also the adjusted savings.
CMS has agreed with these findings and recommendations and has outlined steps for implementing the recommendations.
What does this mean for home care agencies?
While the changes in CMS’s FPS processes shouldn’t affect the day-to-day operations of the Medicaid home care agencies that Arrow Solutions serves, sharpening and enhancing the way in which CMS uses FPS will effectively improve fraud detection and save money within the department, which is good news for everyone!
For more information on other Medicaid and home care agency issues, click here.
As always, whenever changes occur within the industry, the Arrow Solutions home care software team will keep you informed. We are dedicated to keeping our software system and our clients up to date with the latest developments within the home care industry to ensure that your agency runs smoothly at all times. Contact us today to learn more about our home care management system and find out how we can make sure your agency is functioning with the latest information at all times.