CMS Fraud Prevention System (FPS)
A nearly four-year effort by the Centers for Medicare and Medicaid Services to help automate the review of health care claims before, during and after they are filed. A new system called the Fraud Prevention System (FPS) is one of the ?big guns in the government?s battle to reduce improper healthcare claims. FPS is the result of a nearly four-year effort by the Centers for Medicare & Medicaid Services (CMS) to help automate the review of healthcare claims before, during and after they are filed.? Fraud Preventive System uses predictive analytics to catch fraud before CMS pays a claim, which is ?critical? to moving away from the previous ?pay and chase? model.
Fraud Prevention System uses predictive analytics to flag providers and other players in the health care supply chain who might have participated in payment fraud.
As in anti-fraud approaches in the credit card industry, Fraud Prevention System enables CMS to assign risk scores to specific claims and providers, thereby establishing a starting point for analysts to pursue a potential fraud case.
When Fraud Prevention System identifies irregular activity, it automatically generates potential investigative leads for program integrity contractors ? the teams of experts and data scientists who can help identify actions that can be taken immediately, such as suspending payment or launching a case review.
CMS officials say the success of Fraud Prevention System often depends on quickly detecting fraudulent payments, a goal for which it is enhancing some of its response systems. Responding to a suggestion by the Government Accountability Office, CMS has improved the integration of Fraud Prevention System with its claims-processing system, giving Fraud Prevention System the ability to stop payment of improper claims by transmitting a claim denial message directly to the payment system.