While I was out of the office for a few days, I received an e-mail from CMS about a topic I covered only briefly in the past. With a special article serving as clarification, CMS went into further details about predictive modeling techniques currently being utilized to reduce the payment of fraudulent claims, and what this will mean for providers, their patients and networks.

Let me quickly type in an overview of what this means before Word Press explodes.

All claims from June 30th, 2011 and after are being fed into CMS’ predictive modeling technology. The information from the claims is then diced, sliced and analyzed Jetsons-style with regard to provider and patient utilization. This leads to the building of profiles not only of providers, but patients as well.

After all of these high-speed calculations comes the assigning of risk scores based on the data collected. Those entities coming up with higher risk scores will be subject to payment delays, followed by a site visit, reviews of claim histories and interviews by CMS analysts at its discretion. If, after analyst intervention and inquisition, the billing is found to be “innocuous” (you know, like a quilting bee or the Lions Club), that outcome is recorded into the predictive modeling system and the payment for the claim(s) in question is released as usual. 

Now the rough part.

If an analyst finds indications of the not-so-innocuous (you know, like Tony Soprano or Dr. Jekyll), these cases will be referred to CMS’ Center for Program Integrity, the MAC involved and the ZPIC contractor in that particular geographic zone. The result could be targeted denials, revocation of billing privileges, and that classic cinema verite production entitled “A Raid”, featuring veteran co-stars Records Seizure, Perp Walk & Civil Penalty.

The main thrust of this new method is the fact that false claims investigations are no longer a guess, or reliant on someone blowing the whistle on an illegal practice. The government is now using the same types of pre-screening methods that used to be reserved for banks and credit card companies to catch the cheaters in the Medicare program. As a taxpayer, I would say this is about 45 years overdue. As a physician advocate, what I do for a living with regard to practice analytics and documentation review just became very interesting.

Beginning on January 4th, 2010, any claims that include invalid referring physician information will be denied. In addition, any provider who does not appear in the PECOS system with up-to-date information runs the risk of being excluded from the Medicare program for a period of one year.

It is imperative that Medicare remittance advice be watched very closely during this Phase 1 period. For providers who rely on patient referrals for the bulk of their business, such as specialists and laboratories, any warnings received should be shared with the referring providers in question to bring this situation to their immediate attention, as continued non-compliance with this enrollment rule by referring or ordering providers could lead to your claims being denied.

Fortunately, the PECOS system has simplified what can be a laborious enrollment process. Simply go here to begin the process and follow the step-by-step on-screen instructions. After completing this process,  remember to sign and return the two-page certification form within seven days of you PECOS submission. Your information in the PECOS system will not be completed without this step. If you have previously registered with the PECOS system, go here to login to the system and update your information. If you experience technical difficulties during the process, CMS offers help desk support from 7 AM to 7 PM Eastern Time Monday thru Friday either by calling 1-866-484-8049 or by e-mailing .