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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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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.

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Claims processingData integrityEmployee trainingErroneous paymentsFraudInformation technologyLossesMedical expense claimsOverpaymentsPerformance measuresProgram abusesStrategic planningSystems analysisTraining utilizationWork measurementProgram goals or objectivesProgram implementationWaste, fraud, and abuse