This is perhaps good with 2 other companies with data interests involved here as National Government Services already processes Medicare claims for 20 states and the faucet is not turned on presently. As a matter of fact, some of the 3rd party companies who audit all of this are owned by insurance companies too, so can insurance company subsidiaries audit other subsidiaries or CMS interests without conflict of interest? Just a question kicking around in my head.
The algos don’t come along for free and I am guessing it will be closely associated with the WellPoint/Blue Cross commercial claims processes that are used with some modifications to fit CMS. The links below will give you a little history from 2010 as the Wellpoint subsidiary data processes are also being used to determine Physician incentives too, so we have CMS and Medicare with the IT infrastructure they were never allowed to build, all done mostly by insurance companies.
Medicare Contractor Gets Deal to Monitor Physician Incentive Payments–Same Folks Earlier This Week Admonished For Not Doing Enough for Fraud Prevention?
Medicare Fraud Prevention Has Cases Falling Through the Cracks–Looks Who’s Getting the Contracts And Check Out the Algorithms For Their Profitable Business Models
In short it will be interesting to follow how Northrop Grumman and Verizon work with the Wellpoint algorithms and put all of this together and see how well National Government Services polices itself in the 20 state area where they already process Medicare claims. We do need some type of auditing with claims to help detect fraud and it is a good thing, but the parameters and effectiveness with hopefully not a lot of false positives will pay off. BD
Federal Network Systems, Herndon, Va., the Verizon unit, will supply the CMS with a customized version of its predictive modeling technology used to detect fraud and protect security in its telecommunications network, according to a Verizon news release.
National Government Services, the Wellpoint subsidiary also based in Indianapolis, will provide its expertise in fee-for service claims handling, including algorithms for fraud prevention as well as hosting of information technology and infrastructure, a Wellpoint statement said.