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Analysis and applied Best Practices convert deficiency to efficiency, redundancy to succinctness

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The Centers for Medicare and Medicaid Services (CMS) strive to ensure effective, up-to-date health care coverage and to promote high quality care for beneficiaries. The breadth and complexity of this mission makes it extremely vulnerable to fraud. The CMS Center for Program Integrity (CPI) was created in 2010, in part to strategically combat fraud, waste, and abuse with a coordinated approach across CMS and its stakeholders.

The Challenge: Historically, $40-60 billion in fraudulent and improper Medicare claims were paid annually, leaving CMS to recover the lost money.

The Solution: To help CMS stop ineligible medical providers from getting into the program and submitting fraudulent claims, TurningPoint delivered the Advanced Provider Screening Solution (APS), which leverages commercial and government data sources (such as provider licensing, criminal history, government do not pay lists, SSA death master files) to systematically screen each providerís enrollment information and identify those providers who are likely to be fraudulent. This assessment is based on predictive modeling and big data analytics developed jointly by CMS and TurningPoint.

The Result:
  • Since the implementation of APS and other CMS efforts to enhance provider screening, CMS has revoked 28,000 providersí ability to bill the Medicare program, and deactivated enrollments of 470,000 providers in the Medicare program.
  • The APS solution was recognized for its innovative use of Big Data at the 2015 Health IT Innovation Awards sponsored by G2Xchange.
 

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