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May 2012 Launched nearly one year ago, the predictive analytics side of the program, known as the Fraud Prevention System (FPS), processes and monitors 4.5 million claims from Medicare Part A, Part B, and durable medical equipment providers each day using “a complicated and sophisticated set of algorithms to highlight problem areas, to generate alerts that enable the agency to direct its resources accordingly, and to take administrative action,” says Budetti.
The system is designed to help investigators identify and analyze billing patterns in real time, in order to stop potentially fraudulent claims before they’re paid, investigate them, and take action quickly.
In a Los Angeles Times op ed last year, Budetti outlined how the new approach is working.
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May 2012 First-termer Rep. Patrick Meehan (R-Pa.) wants changes to the Medicare and Medicaid programs to give nursing home providers more certainty in their expectations for reimbursement levels, noting he gets the challenges facing the long term and post-acute care sectors at a time of restrained federal and state spending. May 2012 The new National Fraud Prevention Program is based on a data-mining tool known as predictive modeling, which, according to Peter Budetti, director of CMS’ Center for Program Integrity, utilizes a “twin pillars” approach: On the one side is a largely claims-based analytic system that incorporates a wide range of information for the purpose of identifying unusual patterns, while on the other side it screens providers in “a very efficient manner.” May 2012 Despite, or perhaps because of, the swirl of macro-level concerns and headwinds brought on by recession-driven budget deficits and the Accountable Care Act, interest among major payers in the utility of financial incentives to align quality and value in health care purchasing refuses to recede. Sooner or later, nursing home providers will encounter this phenomenon from one or all payers. May 2012 Despite, or perhaps because of, the swirl of macro-level concerns and headwinds brought on by recession-driven budget deficits and the Accountable Care Act, interest among major payers in the utility of financial incentives to align quality and value in health care purchasing refuses to recede. April 2012 Skilled nursing facilities (SNFs) will likely breathe a sigh of relief when fiscal year (FY) 2013 arrives. Provider learned today that instead of a hit in reimbursement, SNFs will get a boost in the form of a prospective payment system (PPS) market basket update of approximately 1.8 percent for FY 2013.
April 2012 In a move that could be a harbinger for similar legislative changes across the country, the bellwether state of New York recently amended portions of its Public Health Law (PHL) in a way that seems to invite more litigation against nursing home providers. April 2012 The National Center for Assisted Living (NCAL) recently released its 2012 edition of “Assisted Living State Regulatory Review,” finding that 16 states made changes to assisted living regulations, statutes, and policies during 2011.
April 2012 A Feb. 21 opinion from the U.S. Supreme Court unanimously upheld the validity and enforceability of pre-dispute arbitration agreements between nursing facilities and their residents. April 2012 Nearly 18 months after implementation of the minimum data set (MDS) 3.0, changes and clarifications are being made to the assessment tool in an effort to ease concerns about the burden it has placed on providers and residents. The changes, which were announced March 7 by the Centers for Medicare & Medicaid Services (CMS) during a training conference in St. Louis, will take effect April 1, 2012. March 2012 The U.S. Department of Health & Human Services 2012 Office of Inspector General (OIG) Work Plan offers providers a helpful overview of Medicare enforcement priorities.
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May 2012 The new National Fraud Prevention Program is based on a data-mining tool known as predictive modeling, which, according to Peter Budetti, director of CMS’ Center for Program Integrity, utilizes a “twin pillars” approach: On the one side is a largely claims-based analytic system that incorporates a wide range of information for the purpose of identifying unusual patterns, while on the other side it screens providers in “a very efficient manner.”
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May 2012 First-termer Rep. Patrick Meehan (R-Pa.) wants changes to the Medicare and Medicaid programs to give nursing home providers more certainty in their expectations for reimbursement levels, noting he gets the challenges facing the long term and post-acute care sectors at a time of restrained federal and state spending. May 2012 The new National Fraud Prevention Program is based on a data-mining tool known as predictive modeling, which, according to Peter Budetti, director of CMS’ Center for Program Integrity, utilizes a “twin pillars” approach: On the one side is a largely claims-based analytic system that incorporates a wide range of information for the purpose of identifying unusual patterns, while on the other side it screens providers in “a very efficient manner.” May 2012 Despite, or perhaps because of, the swirl of macro-level concerns and headwinds brought on by recession-driven budget deficits and the Accountable Care Act, interest among major payers in the utility of financial incentives to align quality and value in health care purchasing refuses to recede. Sooner or later, nursing home providers will encounter this phenomenon from one or all payers. May 2012 Despite, or perhaps because of, the swirl of macro-level concerns and headwinds brought on by recession-driven budget deficits and the Accountable Care Act, interest among major payers in the utility of financial incentives to align quality and value in health care purchasing refuses to recede. April 2012 Skilled nursing facilities (SNFs) will likely breathe a sigh of relief when fiscal year (FY) 2013 arrives. Provider learned today that instead of a hit in reimbursement, SNFs will get a boost in the form of a prospective payment system (PPS) market basket update of approximately 1.8 percent for FY 2013.
April 2012 In a move that could be a harbinger for similar legislative changes across the country, the bellwether state of New York recently amended portions of its Public Health Law (PHL) in a way that seems to invite more litigation against nursing home providers. April 2012 The National Center for Assisted Living (NCAL) recently released its 2012 edition of “Assisted Living State Regulatory Review,” finding that 16 states made changes to assisted living regulations, statutes, and policies during 2011.
April 2012 A Feb. 21 opinion from the U.S. Supreme Court unanimously upheld the validity and enforceability of pre-dispute arbitration agreements between nursing facilities and their residents. April 2012 Nearly 18 months after implementation of the minimum data set (MDS) 3.0, changes and clarifications are being made to the assessment tool in an effort to ease concerns about the burden it has placed on providers and residents. The changes, which were announced March 7 by the Centers for Medicare & Medicaid Services (CMS) during a training conference in St. Louis, will take effect April 1, 2012. March 2012 The U.S. Department of Health & Human Services 2012 Office of Inspector General (OIG) Work Plan offers providers a helpful overview of Medicare enforcement priorities.
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