Predictive Modeling Analysis of Medicare Claims
- Predictive Analytics System analyzes Medicare FFS (Fee-for-service) claims in order to detect fraudulent activity.
The modeling technology goes as follows:
- Builds profiles of providers, networks, billing patterns, and beneficiary utilization
- These profiles create risk scores estimating the likelihood of fraud.
- The profiles are automatically prioritized by which has the most alerts and risk score.
- The analysts at CMS then review the cases which were those of high risk score/ high alert.
- Depending on what the analysts find, they take the appropriate action.
What the risk score does to the claims payment:
- Only alert CMS to review the claims activity
- CMS does not deny claims because of predictive model results
- Enables automated cross-checks
To read the full article, please click the following link: Predictive Modeling Analysis of Medicare Claims
For additional billing, coding, and reimbursement resources, please click the following link: Medical Reimbursement Resources Page