Fraud Detection Systems:

Additional Actions Needed to Support Program Integrity Efforts at Centers for Medicare and Medicaid Services

GAO-11-822T: Published: Jul 12, 2011. Publicly Released: Jul 12, 2011.

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Joel C. Willemssen
(202) 512-6408


Office of Public Affairs
(202) 512-4800

This testimony discusses the Centers for Medicare and Medicaid Services' (CMS) efforts to protect the integrity of the Medicare and Medicaid programs, particularly through the use of information technology to help improve the detection of fraud, waste, and abuse in these programs. CMS is responsible for administering the Medicare and Medicaid programs and leading efforts to reduce improper payments of claims for medical treatment, services, and equipment. Improper payments are overpayments or underpayments that should not have been made or were made in an incorrect amount; they may be due to errors, such as the inadvertent submission of duplicate claims for the same service, or misconduct, such as fraud or abuse. The Department of Health and Human Services reported about $70 billion in improper payments in the Medicare and Medicaid programs in fiscal year 2010. Operating within the Department of Health and Human Services, CMS conducts reviews to prevent improper payments before claims are paid and to detect claims that were paid in error. These activities are predominantly carried out by contractors who, along with CMS personnel, use various information technology solutions to consolidate and analyze data to help identify the improper payment of claims. For example, these program integrity analysts may use software tools to access data about claims and then use those data to identify patterns of unusual activities by matching services with patients' diagnoses. In 2006, CMS initiated activities to centralize and make more accessible the data needed to conduct these analyses and to improve the analytical tools available to its own and contractor analysts. At the Subcommittee's request, we have been reviewing two of these initiatives--the Integrated Data Repository (IDR), which is intended to provide a single source of data related to Medicare and Medicaid claims, and the One Program Integrity (One PI) system, a Web-based portal and suite of analytical software tools used to extract data from IDR and enable complex analyses of these data. According to CMS officials responsible for developing and implementing IDR and One PI, the agency had spent approximately $161 million on these initiatives by the end of fiscal year 2010. This testimony, in conjunction with a report that we are releasing today, summarizes the results of our study--which specifically assessed the extent to which IDR and One PI have been developed and implemented and CMS's progress toward achieving its goals and objectives for using these systems to detect fraud, waste, and abuse.

In 2006, CMS initiated the One PI program with the intention of developing and implementing a portal and software tools that would enable access to and analysis of claims, provider, and beneficiary data from a centralized source. The agency's goal for One PI was to support the needs of a broad program integrity user community, including agency program integrity personnel and contractors who analyze Medicare claims data, along with state agencies that monitor Medicaid claims. To achieve its goal, agency officials planned to implement a tool set that would provide a single source of information to enable consistent, reliable, and timely analyses and improve the agency's ability to detect fraud, waste, and abuse. These tools were to be used to gather data from IDR about beneficiaries, providers, and procedures and, combined with other data, find billing aberrancies or outliers. For example, an analyst could use software tools to identify potentially fraudulent trends in ambulance services by gathering the data about claims for ambulance services and medical treatments, and then use other software to determine associations between the two types of services. If the analyst found claims for ambulance travel costs but no corresponding claims for medical treatment, it might indicate that further investigation could prove that the billings for those services were fraudulent. According to agency program planning documentation, the One PI system was also to be developed incrementally to provide access to IDR data, analytical tools, and portal functionality. CMS planned to implement the One PI portal and two analytical tools for use by program integrity analysts on a widespread basis by the end of fiscal year 2009. The agency engaged contractors to develop the system. While CMS has shown some progress toward meeting the programs' goals of providing a centralized data repository and enhanced analytical capabilities for detecting improper payments due to fraud, waste, and abuse, the current implementation of IDR and One PI does not position the agency to identify, measure, and track financial benefits realized from reductions in improper payments as a result of the implementation of either system. For example, program officials stated that they had developed estimates of financial benefits expected to be realized through the use of IDR. The most recent projection of total financial benefits was reported to be $187 million, based on estimates of the amount of improper payments the agency expected to recover as a result of analyzing data provided by IDR. With estimated life-cycle program costs of $90 million through fiscal year 2018, the resulting net benefit expected from implementing IDR was projected to be $97 million. However, as of March 2011, program officials had not identified actual financial benefits of implementing IDR.

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