Retrieving Billions in Overpayments by CMS

This article focuses on the relatively young technologies that enable CMS to uncover overbillings, whether they be errors or fraud. The article is based on an interview with Kel Pults, chief clinical officer and vice president of MediQuant. A future article will explain how Medicare Advantage plans are trying to improving data collection and reporting, and how AI helps. Challenges of Investigating Overpayments Undeserved payments are needles lurking in the haystack of 135 million Americans enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). But the needles pile up fast. Improper payments for Medicare alone were estimated to be $43 billion for a single year. Conventional fee-for-service payments, which reimburse a doctor for each visit or other intervention, are hard enough to investigate. It’s even harder to determine payments for more open-ended fee-for-value plans, which include Medicare Advantage. Medicare Advantage programs are reimbursed on the basis on how much they are expected to spend on a patient. A person who has smoked for 60 years and is diagnosed with congestive heart failure and diabetes is expected to cost the plan more money than a professional dancer who has maintained an active life style. The difference between these situations drive differences in per-patient CMS reimbursements, which are called “risk-adjusted payments.” But how sick is a patient, really? There are lots of ways to make patients seem sick...
Source: EMR and HIPAA - Category: Information Technology Authors: Tags: AI/Machine Learning Analytics/Big Data Health IT Company Healthcare IT Regulations Revenue Cycle Management #COVID19 CMS COVID Reimbursement Healthcare AI Healthcare Analytics Kel Pults MAOs Medicare Advantage MediQuant Overp Source Type: blogs