CMS Efforts To Use Software to Detect Fraud

CMS uses contractors to process claims, but also to use sophisticated software to detect fraud patterns and make referrals for claims denials, audits and criminal investigations. At one time the system was somewhat fragmented, given that there are different contractors who process part A, B and D claims in given regions and a series of contractors were looking at data based upon particular types of claims or criteria. In addition, the flow of data prevented the contractors from analyzing and detecting fraud patterns until long after claims had been paid. Lately, CMS has moved to contractors who electronically review all claims for 7 regions searching for claims patterns that reflect fraud. The program, called ZPIC (Zone Program Integrity Contractors) has led, at least at the inception, to many providers receiving audit inquiries, chart reviews, and application renewals; and according to the program, the denial of $1.5 billion in claims in Florida alone since May.
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