Wednesday, February 27, 2013

Predictive Modeling Analysis of Medicare Claims

Since June 30, 2011, Medicare has implemented a predictive analysis system. The following bullets explains the predictive modeling anaylysis in more detail.

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