CMS seeks software to auto-deny bad claims
By Mary Mosquera
Monday, August 17, 2009
The Centers for Medicare and Medicaid Services wants to know what automated technology is available that can help it reduce the number of incorrect payments it makes for fraudulent or flawed healthcare claims. CMS published a request for information Aug. 11 about the latest commercial software that could automatically flag and deny claims before the Medicare program pays them.
CMS paid out a whopping $10.3 billion in erroneous payments in 2007, according to a review in 2008 by the Office of Management and Budget. Medicare is in the top three federal programs racking up the most improper payments, OMB said.
Commercial firms process Medicare fee-for-service claims on behalf of CMS, as well as make payments and apply analysis software after payment goes out to physicians, hospitals and durable medical equipment suppliers
“There is growing concern that the Medicare Trust Funds may not be adequately protected against erroneous payment through current administrative procedures,” CMS said in its posting on the Federal Business Opportunities Web site.
CMS will also host a meeting in September to share more details about the project with interested companies and organizations. Responses to the RFI are due Sept. 24. The subsequent contract or contracts will be for one year with the option for four more years.
“Medicare is committed to preventing erroneous payments,” said George Mills Jr., director of the provider compliance group in CMS’ Office of Financial Management, which is leading the project. That’s why CMS is considering new software that can automatically deny a claim. “By automatically, we mean claims that do not require human review and are supported by clear policy,” he said.
Improper payments for claims can occur because the services do not meet Medicare’s medical necessity criteria; the healthcare services are not coded correctly; or the claim may be a duplicate, Mills said.
