{
  "id": "AIBD-0186",
  "title": "CMS's Fraud Prevention System identifies or prevents $654.8 million in 2015, an $11.5-to-$1 return on investment",
  "summary": "CMS's return-on-investment report for the Fraud Prevention System's fourth implementation year counts $654.8 million in inappropriate Medicare payments identified or prevented in 2015 against $57.1...",
  "date_observed": "2015-12-31",
  "date_basis": "unassessed",
  "date_precision": "unassessed",
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  "account": "The Centers for Medicare and Medicaid Services' report “Fraud Prevention System Return on Investment, Fourth Implementation Year” is undated. The Wayback Machine archived it on 24 August 2016. It states the FPS helped identify or prevent $654.8 million in inappropriate payments during calendar year 2015, about 44% more than the previous year. That counts actions taken due to the FPS and investigations it expedited, augmented or corroborated. The corrected ROI is $11.5 to $1, after a rounding error in the originally reported $11.6. Table 1 trends identified savings from $115.4 million in the first year (July 2011 to June 2012) through $250.1 million and $454.0 million. The cumulative total is $1,474.3 million. Savings are split across pre-payment edit denials, payment suspensions, projected cost avoidance from revoking billing privileges and overpayments referred for recovery. The value of law-enforcement referrals was $49.2 million in 2015. The report says the methodology was certified by the HHS Office of Inspector General. It puts 45 providers on active payment suspension at year end. Costs were an estimated $57.1 million, including $19.5 million for a developing contractor and $4.8 million for a modeling contractor. The report does not describe the system's technique.",
  "category": "general benefit",
  "unexpected": false,
  "purpose": "Identify or prevent inappropriate Medicare payments by generating leads that program-integrity contractors investigate and act on.",
  "system": "Fraud Prevention System (FPS)",
  "model_version": null,
  "developer": "Contractors engaged by CMS (the report lists 'Developing Contractor Costs' and 'Modeling Contractor Costs' without naming firms)",
  "deployer": "Centers for Medicare and Medicaid Services (CMS)",
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  "domain": "Health insurance fraud and improper payments",
  "segment": "Medicare program integrity",
  "benefit_type": "Reduced Risk",
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  "ratings": [
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      "reason": "The report gives aggregate identified savings for CMS with no single attributable case."
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    "statement": "The report counts savings from actions taken due to the FPS and from investigations the FPS expedited, augmented or corroborated. So the system's own contribution cannot be separated from investigators' work. The technique is not described. CMS deployed the system and paid unnamed developing and modeling contractors, so developer and deployer are not the same body."
  },
  "evidence": [
    {
      "kind": "report",
      "citation": "Centers for Medicare and Medicaid Services, 'Fraud Prevention System Return on Investment, Fourth Implementation Year', undated (covers 1 January to 31 December 2015; archived 24 August 2016)",
      "title": "Fraud Prevention System Return on Investment, Fourth Implementation Year",
      "url": "https://web.archive.org/web/20160824134124/https://www.cms.gov/about-cms/components/cpi/downloads/fraud-prevention-system-return-on-investment-fourth-implementation-year-2015.pdf",
      "date": null,
      "written_by": "deployer",
      "quote": "The FPS helped identify or prevent $654.8 million in inappropriate payments during calendar year 2015"
    }
  ],
  "replication": {
    "produced_by": [
      "Claims data run through FPS edits and models that generate leads for Zone Program Integrity Contractors",
      "Administrative levers listed in Table 1 (pre-payment edits, payment suspensions, revocation of billing privileges, overpayment referrals, law-enforcement referrals)"
    ],
    "must_hold": [
      "Statutory basis and funding (the Small Business Jobs Act of 2010 defines the implementation years)",
      "Contractor capacity to investigate leads (investigation costs of $28.9 million in 2015)",
      "A savings methodology certified by HHS-OIG"
    ],
    "echoes": [
      {
        "date": "2012-06-30",
        "setting": "First implementation year, July 2011 to June 2012",
        "model_version": null,
        "outcome": "recurred",
        "source": "Table 1: $115.4 million identified savings"
      },
      {
        "date": "2013-09-30",
        "setting": "Second implementation year, October 2012 to September 2013",
        "model_version": null,
        "outcome": "recurred",
        "source": "Table 1 and note 4: $210.7 million certified plus $39.4 million attributed, $250.1 million"
      },
      {
        "date": "2014-12-31",
        "setting": "Third implementation year, calendar 2014",
        "model_version": null,
        "outcome": "recurred",
        "source": "Table 1: $454.0 million"
      }
    ]
  },
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  "headline": "CMS's FPS identifies or prevents $654.8 million in 2015",
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    "against": "the FPS's identified savings in the previous year, 2014",
    "before": "identified savings from the previous year ($454.0 million in Table 1)",
    "after": "$654.8 million",
    "basis": "measured",
    "quote": "The FPS helped identify or prevent $654.8 million in inappropriate payments during calendar year 2015 through actions taken due to the FPS or through investigations expedited, augmented, or corroborated by the FPS (Table 1). These identified savings were about 44% higher than the identified savings from the previous year, with a nearly $11.51 to $1 ROI.",
    "url": "https://web.archive.org/web/20160824134124id_/https://www.cms.gov/about-cms/components/cpi/downloads/fraud-prevention-system-return-on-investment-fourth-implementation-year-2015.pdf"
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    "quote": "The FPS helped identify or prevent $654.8 million in inappropriate payments during calendar year 2015 through actions taken due to the FPS or through investigations expedited, augmented, or corroborated by the FPS (Table 1).",
    "url": "https://web.archive.org/web/20160824134124id_/https://www.cms.gov/about-cms/components/cpi/downloads/fraud-prevention-system-return-on-investment-fourth-implementation-year-2015.pdf"
  },
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      "change": "Benefit type set to Reduced Risk under Trustible's full taxonomy of 23 types; it was Improved Organizational Efficiency among the six first used.",
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        "review_state": "record_mapped",
        "coverage": "partial"
      }
    },
    "summary": {
      "total": 91,
      "addressed": 91,
      "known": 29,
      "reviewed": 0,
      "record_mapped": 29,
      "not_assessed": 62,
      "complete": false,
      "by_state": {
        "value_present": 29,
        "not_reported": 0,
        "unresolved": 0,
        "not_assessed": 62,
        "not_applicable": 0,
        "withheld": 0,
        "source_unavailable": 0
      }
    }
  }
}