The Centers for Medicare & Medicaid Services (CMS) recently announced the Program Integrity Commend Center in Baltimore to what it hopes will speed up anti-fraud efforts.
It’s a $3.6 million facility. Equipped with a couple of dozen computer workstations, giant screens and new computerized detection systems, the facility will pull together some of the country’s biggest experts in the government’s campaign to fight fraud, the Associated Press reported. The Obama administration is asking Congress for $2 million to operate the command center.
Several members from Congress, the Department of Health and Human Services (HHS), and the media, obtained invitations to walk through the new center. The invitation to cover the event said reporters would see “examples of real-time missions,” but Medicare spokesman Brian Cook acknowledged that all they were shown were “demonstrations” of how the command center is supposed to work.
Republicans, however, are not yet convinced the brand new facility is worth the taxpayer dollars. As we noted back in April of this year, Senators from both sides of the aisle expressed concern about CMS’ Fraud Prevention System (FPS) as part of the National Fraud Prevention Program (NFPP), which was adopted by CMS fulfilling the mandates in the Small Business Jobs Act of 2010. In fact, the system, which went online in mid-2011, had prevented exactly one bad claim by late last year. That totaled $7,591. The new system and center will have to report to Congress soon on its progress.
This new command center comes in addition to the recent launch of a ground-breaking partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud. “This voluntary, collaborative arrangement uniting public and private organizations is the next step in the Obama administration’s efforts to combat health care fraud and safeguard health care dollars to better protect taxpayers and consumers.”
Issues with New Command Center and FPS
Senators Orrin Hatch (R-Utah) and Tom Coburn (R-Oklahoma) said the Obama administration isn’t providing enough information about the FPS and new computer systems being used to identify suspicious Medicare and Medicaid billings. Computerized screening of claims is at the heart of the command center’s mission. The Senators requested specific data regarding performance metrics, targeting of claims for review and actual program results.
“After our offices saw a live demonstration of the FPS, we have concluded there is a significant disconnect between the rhetorical claims made by the administration and the system’s actual current operational status,” Senators Hatch and Coburn wrote in a letter to CMS Acting Administrator Marilyn Tavenner.
Although CMS called the system “mature” and spent $77 million to procure the contract for FPS, Hatch and Coburn said “the number of predictive analytic algorithms, or ‘models,’ being applied to the live payment stream are underwhelming at best. CMS should have hundreds of models in operation, but instead there is a handful, and even the contract fulfillment only requires a few dozen.”
The Senators also noted that very few models were specifically designed to target procedures, services or supplies at high risk for fraud. They also expressed their concern that the video screen alone cost “several hundred thousand dollars.”
“Institutionalizing relationships through establishing a (command) center may be useful, but if huge sums of money have indeed been spent on a video screen while other common-sense recommendations may have not been implemented due to ‘resource concerns,’ this seems to be a case of misplaced priorities,” the senators wrote. They noted that “CMS needs to do a better job prioritizing what claims are under review and how those claims are reviewed. Rather than merely prioritize the “top 10” possible fraudulent claims or schemes, they recommended that CMS maximize its efforts with law enforcement and its contractors to review dozens, even hundreds, of flagged claims concurrently.
The Senators noted that CMS seems to agree with the idea that the FPS can demonstrate its effectiveness. In an announcement earlier this year, CMS said that “reversing the traditional pay-and-chase approach to program integrity is the main goal of the National Fraud Prevention Program (NFPP).” Despite this rhetorical commitment, the Senators recognized that “CMS has not been fully transparent regarding what progress the agency is making in implementing the system and how successful the efforts of the system have been to date.”
In hearings, meetings, and public letters over the past several months, the Senators have repeatedly pressed CMS for a set of specific metrics and timelines for the implementation of the FPS and the metrics for measuring its performance, including the agency’s view on “what determines success.” The responses have been polite, “but vague and largely qualitative.” The Senators said this is concerning, because the old adage is true: “one cannot manage what one cannot measure.”
CMS, however, touted the new facility, which will bring together clinicians, data analysts, fraud investigators and policy experts in one physical space to “build and improve our sophisticated new predictive analytics that spot fraud, and to then move quickly on a lead, once potential fraud is identified,” Peter Budetti, CMS deputy administrator and director of the Center for Program Integrity, said in a blog post. That coordination will help authorities move faster on investigations that usually take days or weeks to just hours, according to CMS.
Budetti said the goal is to let the government’s far-flung gumshoes talk directly with the experts running the new computerized detection systems, dramatically reducing the time it takes to conduct investigations. “Our expectation is that this center will pay for itself many times over,” Budetti said in the AP article. Medicare currently loses an estimated $60 billion dollars each year to waste, fraud and abuse.
Conducting what amounted to her first formal inspection, HHS Secretary Kathleen Sebelius set the bar high for the command center. She told staffers it’s time for the government to move beyond its old strategy of “pay and chase,” pursuing fraudsters after Medicare and Medicaid have already paid. “Preventing fraud and abuse is what this effort is about,” she said.
The secretary spoke with three groups of staffers: one responsible for developing computer models to query billing data for suspicious patterns; another in charge of investigating data generated by the computer models, looking for mistakes as well as real fraud; and a third handling coordination with law enforcement around the country. Staffers said they expect the coordination to cut the time it takes to investigate suspected fraud schemes from months to days and weeks.
Request for Information
In concluding their letter, Senators Hatch and Coburn asked CMS to submit to them by
this past September, the following information:
- A work plan for the FPS for the next six quarters, outlining specific goals, deliverables, timeframes, and metrics for evaluation.
- An explanation of how the “One PI” (One Program Integrity –an effort to coordinate all PI pieces adopted by CMS in recent years) fits with FPS and NFPP.
- An explanation of how the Integrated Data Repository and One PI efforts are now funded.
- An explanation of the need for the “command center” in Baltimore to run the FPS, as well as an account of the expenditures and staffing associated with the new “command center.” Please clarify the role and integration of the ZPIC staff with regard to the new center and what is different about the new center that requires its establishment.
- A specific explanation of how the fraud referrals from the 1-800 Medicare hotline –some of which have reportedly already been examined by the ZPICs and discarded —are now being integrated into the FPS.
- An explanation of the additional steps CMS must take if contractors identify false store fronts for Medicare billing addresses using technologies like Google Earth.
- A detailed explanation of the institutionalized feedback mechanisms CMS has in place to develop new models based on the experience, insight, and advice of all of its program integrity contractors.
- An explanation of how CMS handles cases of alleged or possible fraud that law enforcement declines to pursue.
- A timeframe for when CMS will comprehensively outline how it will assess the success of the FPS system.
- An explanation of what other possible revisions or modifications CMS may be considering to current auditing procedures, including changes to the scope of work for various CMS contractors.
- A detailed breakdown of all costs associated with FPS and the NFPP including administrative, implementation and operational costs. Please include specific information about how the $77 million paid for the FPS contract is being divided amongst the various contractors and subcontractors working on FPS as well as detailed accounting of all costs, including staffing, for the FPS command center in Baltimore.
- An explanation of why CMS has not to date, been able to solely use FPS to stop any claims before they are paid.
- An explanation of why CMS has not used its exclusion authority to prevent fraudulent providers from continuing to bill the Medicare program.
- A detailed breakdown of what dollar amount has been recouped as a direct result of enforcement actions taken against providers or suppliers who were first identified as problematic through FPS.
- A detailed explanation of what actions CMS took in response to our identifying more than three dozen physicians and non-physician practitioners with felony convictions or guilty pleas who have retained their Medicare billing privileges and/or the ability to order and refer in the Medicare program in November of last year. Please details when actions were taken with regard to each individual.
In addition, the Senators noted the new public-private partnership, and requested the following information (citing vagueness in this proposed partnership):
- Specifics regarding exactly how this collaboration will work including what entities will be involved, whether HHS/CMS or another entity will be overseeing the effort and a timeline for expected key milestones of the effort.
- A step-by-step explanation of how the information will be shared (e.g., what systems will be used to transmit the data), what authorities allow the exchange of information, what impediments exist to sharing information (e.g., statutory language) and where the information will be stored/analyzed.
- A description of the third party who will be analyzing the data, as well as an explanation of how that entity will be selected and what their capabilities are to integrate and analyze such a large amount of information.
- Specifics regarding what will happen when leads are identified, how that information will be disseminated, and what the process will be for following up on those leads.
Conclusion
Just like alot of other projects the CMS Anti-Fraud Center may not be working on opening day but over time that should change considerably. As with any new venture, it will take some time to work the bugs out. Hopefully in the end, under the right leadership it will work out.