fraud detection

Latest Headlines

Latest Headlines

When measuring fraud prevention systems, honest analysis is critical to improvement

A recent CMS announcment revealed an impressive 10 to 1 retrun on investment in the agency's relatively new Fraud Prevention System. But these figures may be smaller than they appear. A concurrent OIG assessment found that the true value was closer to 3 to 1. The discrepancy speaks to CMS' willingness to inflate statistics for the sake of public perception, but to a larger degree it should serve as a lesson to all payers that accurate analysis is crucial to refining the new fraud detection systems. 

N.Y. lawmakers push for one-year delay on electronic prescribing requirement

As providers and pharmacists in New York prepare for a state-wide electronic prescribing mandate set to go into effect this month, state lawmakers are pushing to extend the deadline another year, thanks to a recent bill that awaits Gov. Andrew Cuomo's signature.  

Cleaning up the mess in Texas requires a culture change

Developing a culture of compliance is imparative to fraud prevention. Over the last several months, as the Texas Health and Human Services Commission's Office of Inspector General has become further embroiled in controversy, i'ts become clear that leaders at the agency developed a culture that led to mismanagement of the entire fraud prevention program. Now that two of the agency's top officials haver resigned, perhaps the state can start anew. 

Top Texas officials resign following fraud detection contract scrutiny

After months of scrutiny, two top officials at the Texas Health and Human Services Commission's Office of Inspector General are out of jobs amid questions surrounding a $110 million Medicaid fraud software contract.

CMS strengthens oversight of Medicare providers

The Centers for Medicare & Medicaid Services has introduced new "common-sense safeguards" that have removed nearly 25,000 "bad actors" from Medicare, CMS said in a statement today.

Fraud hotlines: Decide who answers the phone

Tip lines can be valuable tools for gathering fraud intelligence, and companies should weigh four factors to decide whether to run an internal hotline or outsource this function, according to  JD Supra Business Advisor.

A peek at what powers federal fraud detection

Congress recently learned how algorithms of the government's fraud prevention system work, according to a blog post by Deniza Gertzberg, J.D. Using the FPS led to actions against 938 providers in fiscal 2013, saving or preventing more than $200 million in overpayments.

Crowdsourcing: The next big thing in fraud detection?

Harnessing the power of crowdsourcing is a fresh idea proposed to supplement tried-and-true methods of identifying health insurance fraud.

WellPoint's Patrick McIntyre on anti-fraud analytics partnerships

FierceHealthPayer: Anti-Fraud spoke to Patrick McIntyre for expert advice on smart shopping for anti-fraud data analytics and how to work well with vendors. McIntyre is senior vice president of healthcare analytics at Wellpoint.    

Fraud prevention: Decipher the claims data story

Payers sift through and analyze millions of provider claims, working to prevent fraud and cut costs. They rightly consider these claims as valuable points of information that help identify...