Over the past five years, the Centers for Medicare & Medicaid Services (“CMS”) has used “big data” and predictive analytics approaches to fight fraud, waste, and abuse in the Medicare fee-for-service program.

According to a recent post on the official CMS blog, the Fraud Prevention System’s “big data” effort has given CMS the ability to better connect with predictive analytics experts and data scientists, and collaborate more closely with law enforcement. Through the Fraud Prevention System, CMS has “moved beyond the reactive ‘pay and chase’ approach” toward a more proactive approach aimed at preventing illegitimate payments in the first place.

As described in the CMS post, the Fraud Prevention System’s “big data” effort “has had a profound impact on fraudulent providers and illegitimate payments by allowing [CMS] to quickly identify issues and take action.” The technology has contributed to more than $1 billion in savings in 2014 and 2015. And, in 2015, CMS realized a national return-on-investment of $11.60 for every dollar the federal government spends on this effort.

CMS is now working to develop next-generation predictive analytics and a new system design to further improve the usability and efficiency of the Fraud Prevention System.

Photo of Krysten Rosen Moller Krysten Rosen Moller

Krysten Rosen Moller focuses her practice on representing clients in internal investigations, government investigations, and follow-on civil litigation, with an emphasis on serving clients in the life sciences and healthcare industries.

Krysten assists companies with complex internal and government investigations covering a broad…

Krysten Rosen Moller focuses her practice on representing clients in internal investigations, government investigations, and follow-on civil litigation, with an emphasis on serving clients in the life sciences and healthcare industries.

Krysten assists companies with complex internal and government investigations covering a broad range of issues, including fraud and abuse, advertising and promotion, and bribery and corruption. Krysten has particular experience conducting targeted and efficient internal investigations and representing pharmaceutical and medical device companies against investigations from the Department of Justice or other government regulators. Krysten’s complementary litigation practice focuses on defending life sciences and healthcare companies in related litigation, including cases arising under the False Claims Act and other follow-on litigation arising from government investigations.

Krysten also counsels clients on compliance matters. She regularly represents companies negotiating HHS OIG Corporate Integrity Agreements (CIAs) and advises companies on implementing and operating under CIAs. She has also conducted False Claims Act risk assessments and advised on other fraud and abuse issues.