Twin Pillar Strategy to Prevent and Detect Fraud in the Federal Health Care Programs

Center for Medicare and Medicaid Services (CMS) directly manages Medicare by way of contracts with private companies that process claims for Medicare Advantage. While Medicaid is managed by the States within the limits of Federal law and regulations and CMS works with each State Medicaid program to prop up program integrity efforts.

A twin pillar approach has been executed by the CMS to prevent fraud in Medicare build upon program integrity efforts aimed at identifying and acting against fraud. The first pillar is the new Fraud Prevention System (FPS) that employs analytical technology on claims before payment to spot anomalous and suspicious billing patterns. The second pillar is the Automated Provider Screening (APS) system, which identifies disqualified providers or suppliers before they are enrolled. These new systems, the FPS and APS, are rapidly spreading its efforts to protect patients and taxpayers against those trying to deceive Medicare Plans programs. These pillars embody a broad approach to program integrity by checking fraud before payments are made, keeping defaulters away from Medicare and promptly eliminating them from the program once they are identified.

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