Roskam Bill Saves Medicare Tens of Billions





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Published on Jun 15, 2010

"Tens of billions of dollars are stolen from Medicare every year that can be easily saved. My amendment has been developed and modified since last summer. It will both measure the amount of Medicare fraud more accurately and protect the Medicare trust fund from billions of dollars in fraud.

My legislation will reform Medicare's payment claims by directing the Centers for Medicare and Medicaid Services Office of Program Integrity to design a comprehensive pre-payment predictive modeling system to be applied prior to reimbursing claims. Strengthening claims at the front end of the payment system will prevent suspect claims from being reimbursed. Predictive modeling detects fraudulent claims that traditional rule-based edits cannot identify.

Predictive modeling was the solution to rampant fraud within the financial services industry. It was first utilized by the financial services industry in the early 1990s to model consumer behavior. Within five years, 80 percent of financial services institutions had implemented predictive modeling. The industry, which handles $11 trillion in transactions early, suffers only .047 percent in fraud due to this system. Predictive modeling "scores" a claim to identify claims that have a high probability of fraud. A predictive model creates an estimated score on claims using historical data and then continually evolves. That estimate is then applied to new claims that are submitted. Highly suspicious claims are subject to manual review to avoid false-positives and a provider self-audit appeal process."

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