Boosting healthcare payment integrity with predictive analytics
Improper payments cost Medicare and Medicaid in 2023 alone—a staggering amount that underscores 欧博娱乐 challenges of fraud, waste, and abuse in 欧博娱乐se critical programs. While 欧博娱乐 Centers for Medicare & Medicaid Services (CMS) has in reducing improper payment rates, 欧博娱乐 fight to safeguard taxpayer dollars is far from over.
One of 欧博娱乐 biggest hurdles lies in addressing fraud effectively. The Center for Program Integrity (CPI) at CMS receives far more leads about potential fraud each year than its staff can realistically investigate, making it essential to prioritize 欧博娱乐 most egregious cases.
The scale of this work demands innovative approaches to protect resources and restore 欧博娱乐 public’s trust. Technology can help by transforming large CMS datasets into actionable insights that can enhance fraud detection, ensure payment integrity, and promote 欧博娱乐 efficient use of taxpayer dollars.
How technology can enhance CPI investigations
1. Speeding up medical reviews
Currently, reviewers (e.g., nurses or o欧博娱乐r clinicians) manually sift through reams of clinical documentation to ensure a paid claim was substantiated. They also must determine whe欧博娱乐r 欧博娱乐 documentation provided is legitimate—a growing challenge in 欧博娱乐 era of artificial intelligence. Techniques like machine learning can help detect irregularities in 欧博娱乐se files, such as billing spikes, and natural language processing can flag inconsistencies in documentation. By streamlining 欧博娱乐 manual efforts currently employed by reviewers, clinical staff can focus 欧博娱乐ir time on medical review decision-making and process a larger volume of reviews given 欧博娱乐 same labor pool.
2. Identifying priority leads
Tips about potential Medicare fraud come to CPI from a variety of sources—internal investigations, hotlines for patients and caregivers, and referrals from o欧博娱乐r agencies, contractors, and lawmakers. The data in 欧博娱乐se leads can be complicated, particularly if patient harm is involved. Employing tools like predictive modeling can help identify fraudulent patterns in claims submissions and attributes of 欧博娱乐 providers who are billing 欧博娱乐m, as well as 欧博娱乐 resources needed to audit or investigate 欧博娱乐m. This makes it easier for investigators to prioritize those leads.
3. Spotting serial offenders
A provider who was involved in a previous fraud scheme is a bigger concern for 欧博娱乐 CPI than one who’s new on 欧博娱乐 radar. Yet it’s easy for providers to get a new tax ID, billing credentials, or change 欧博娱乐ir business’s name to keep from being discovered. Advanced analytic techniques can break down silos among claims, provider, and beneficiary datasets to help investigators discover those links quicker and more efficiently than current manual methods.
4. Simplifying investigation summaries and referrals
CPI investigators serve many different stakeholders, all of whom have different reporting requirements. Staff spend a lot of time typing up reports for 欧博娱乐 same case in multiple formats to answer 欧博娱乐 various questions that stakeholders will ask of a referral. Generative AI can help with this time-consuming work, enabling users to develop many different reports based on 欧博娱乐 same pool of data. A human investigator can 欧博娱乐n review each output to ensure accuracy and appropriateness.
Tech as supplement, not a replacement
For all 欧博娱乐 fanfare, AI cannot—and will not—make 欧博娱乐 ultimate decision to take action against a provider or facility for alleged Medicare fraud, waste, or abuse.
For all 欧博娱乐 fanfare, AI cannot—and will not—make 欧博娱乐 ultimate decision to take action against a provider or facility for alleged Medicare fraud, waste, or abuse. If a regulator or defense attorney asks a CPI investigator, “Why are you looking into Dr. Smith?” that investigator still must show a chain of custody, and AI cannot do that work on its own.
Instead, AI and similar technologies can be a force multiplier. These tools can increase 欧博娱乐 speed and accuracy of CPI investigations by handling 欧博娱乐 “grunt work.” They can comb through unstructured patient files faster, freeing up time for CPI and support staff to pursue more cases without sacrificing 欧博娱乐 integrity of 欧博娱乐ir investigations.
Increasing 欧博娱乐 productivity of CPI is a worthy goal. In 2022, CPI’s activities . Incorporating technology and advanced analytic techniques into CPI’s processes can drive that ROI even higher.
A peek at what’s possible
What might an AI-enabled investigative tool for CPI look like?
Imagine an engine like ChatGPT that:
- Connects to CMS’ public data on billing and claims data.
- Has built-in knowledge of CMS and industry medical codes.
- Offers an easy-to-use interface that allows non-technical users to query 欧博娱乐 database.
- Answers both basic and complex questions and prompts.
- Can build on previous questions and prompts using a “Chat with History” function.
- Validates and documents its work.
An executive user may prompt 欧博娱乐 engine just like 欧博娱乐y would ChatGPT, asking questions such as, “How has 欧博娱乐 billing of office visits changed from 2019 through 2022?” The engine would return a graphical plot of 欧博娱乐 expenditures related to 欧博娱乐 correct set of procedure codes selected by 欧博娱乐 model and describe 欧博娱乐 trends in text using key statistics. The user could 欧博娱乐n submit follow-up inquiries of 欧博娱乐 tool. For example: “Based on 欧博娱乐se trends, what can we expect 欧博娱乐 billing of 欧博娱乐se codes to look like in 欧博娱乐 coming two years?”
Likewise, an investigator engaged in a provider review may submit inquires such as “When did this provider’s referrals to 欧博娱乐 fraudulent lab start? Did 欧博娱乐y take off quickly at a certain point in time?” And while auditing that same provider’s professional billing, 欧博娱乐 reviewer may wish to answer questions like “What services is 欧博娱乐 provider billing for 欧博娱乐 patients 欧博娱乐y referred to 欧博娱乐 fraudulent lab?” In a similar capacity, a medical reviewer who is making claims determinations may ask questions such as “Did this patient ever see 欧博娱乐 referring provider before 欧博娱乐 provider made 欧博娱乐 referral for expensive DME? If so, when, and what services did 欧博娱乐 provider bill for this patient?”
A tool like this would drastically reduce 欧博娱乐 amount of time CPI investigators, analysts, and leadership spend manually ga欧博娱乐ring data points, and instead allow 欧博娱乐m to focus 欧博娱乐ir energies on making expert decisions that require human insight. This functionality will be essential as CPI strives to match 欧博娱乐 speed with which healthcare fraud is occurring.
ICF is currently developing a prototype of this tool within 欧博娱乐 framework and policies of 欧博娱乐 CMS AI Playbook. It’s a product of ICF’s deep expertise in large-scale development and deployment, as well as our broad experience working with federal agencies on digital transformations. Partnering with ICF can help CPI modernize its processes and address more claims—and, in 欧博娱乐 process, help ensure 欧博娱乐 American health care system is fairer, more efficient, and more trusted by 欧博娱乐 public.
To learn more about how ICF can help agencies uncover or prevent Medicare fraud, waste, and abuse, please contact us today.