MEDICARE

CMS Fraud 

Prevention System 

Uses Claims Analysis 

to Address Fraud

Report to Congressional Requesters

August 2017

GAO-17-710

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-710, a report to 

congressional requesters

August 2017

MEDICARE

CMS Fraud Prevention System Uses Claims Analysis 

to Address Fraud

What GAO Found

Investigations initiated or supported by the Centers for Medicare & Medicaid 

Services’ (CMS) Fraud Prevention System (FPS)—a data analytic system—led 

to corrective actions against providers and generated savings. For example, in 

fiscal year 2016, CMS reported that 90 providers had their payments suspended 

because of investigations initiated or supported by FPS, which resulted in an 

estimated $6.7 million in savings. In fiscal year 2016, 22 percent of Medicare 

fraud investigations conducted by CMS program integrity contractors were based 

on leads generated by FPS analysis of Medicare claims data. Officials 

representing Medicare’s program integrity contractors told GAO that FPS helps 

speed up certain investigation processes, such as identifying and triaging 

suspect providers for investigation. However, the officials said that once an 

investigation is initiated, FPS has generally not sped up the process for 

investigating and gathering evidence against suspect providers. CMS has not 

tracked data to assess the extent to which FPS has affected the timeliness of 

contractor investigation processes. However, CMS is implementing a new 

information technology system that tracks such data, and officials said that they 

plan to use the data to assess FPS’s effect on timeliness.

FPS denies individual claims for payment that violate Medicare rules or policies 

through prepayment edits—automated controls that compare claims against 

Medicare requirements in order to approve or deny claims. FPS prepayment 

edits specifically target payments associated with potential fraud. For example, 

an FPS edit denies physician claims that improperly increase payments by 

misidentifying the place that the service was rendered, which helped address a 

payment vulnerability associated with millions in overpayments. FPS edits do not 

analyze individual claims to automatically deny them based on risk alone or the 

likelihood that they are fraudulent without further investigation. As of May 2017, 

CMS had implemented 24 edits in FPS. CMS reported that FPS edits denied 

nearly 324,000 claims and saved more than $20.4 million in fiscal year 2016. 

The Healthcare Fraud Prevention Partnership (HFPP) is a public-private 

partnership that began in 2012 with the aim of facilitating collaboration among 

health care payers to address health care fraud. The HFPP had 79 participants 

as of June 2017. Participants, including CMS officials, stated that sharing data 

and information within HFPP has been useful to their efforts to address health 

care fraud. HFPP conducts studies that pool and analyze multiple payers’ claims 

data to identify providers with patterns of suspect billing across payers.

Participants reported that HFPP’s studies helped them to identify and take action 

against potentially fraudulent providers and payment vulnerabilities of which they 

might not otherwise have been aware. For example, one study identified

providers who were cumulatively billing multiple payers for more services than 

could reasonably be rendered in a single day. Participants also stated that HFPP 

has fostered both formal and informal information sharing among payers. 

The Department of Health and Human Services provided technical comments on 

a draft of this report, which GAO incorporated as appropriate. View GAO-17-710. For more information, 

contact Kathleen M. King at (202) 512-7114 or 

kingk@gao.gov.

Why GAO Did This Study

CMS analyzes Medicare fee-forservice claims data to further its 

program integrity activities. In 2011, 

CMS implemented a data analytic 

system called FPS to develop leads for 

fraud investigations conducted by CMS 

program integrity contractors and to

deny improper payments. In 

developing leads, FPS is intended to 

help CMS avoid improper payment 

costs by enabling quicker 

investigations and more timely 

corrective actions. Additionally, in 

2012, CMS helped establish the HFPP

to collaborate with other health care 

payers to address health care fraud.

One of the key activities of the HFPP is 

to analyze claims data that are pooled 

from multiple payers, including private 

payers and Medicare. 

GAO was asked to review CMS’s use 

of FPS and the activities of the HFPP. 

This report examines 1) CMS’s use of 

FPS to identify and investigate 

providers suspected of potential fraud, 

2) the types of payments that have 

been denied by FPS, and 3) HFPP 

efforts to further CMS’s and payers’ 

ability to address health care fraud. 

GAO reviewed CMS documents, 

including reports to Congress on FPS, 

contractor statements of work, and 

information technology system user 

guides, and obtained fiscal year 2015 

and 2016 data on FPS fraud 

investigations and claim denials. GAO 

also interviewed CMS officials and

CMS program integrity contractors

regarding how they use FPS, and a 

non-generalizable selection of HFPP 

participants regarding information and 

data sharing practices, and anti-fraud 

collaboration efforts.
Page i GAO-17-710 CMS Fraud Prevention System

Letter 1

Background 4

CMS Program Integrity Contractors Reported That FPS Speeds 

Up Certain Investigation Processes and Has Contributed to 

Program Savings 12

FPS Denies Payments Based on Medicare Rules or Policies and 

Not Fraud Risk 18

Participants Reported That HFPP Efforts Furthered Their Ability to 

Address Health Care Fraud 20

Agency Comments 24

Appendix I GAO Contact and Staff Acknowledgments 27

Tables

Table 1: Administrative Actions Against Medicare Providers That 

May Result from Program Integrity Investigations 9

Table 2: Sources of Zone Program Integrity Contractor (ZPIC) 

Investigations, Fiscal Years (FY) 2015 and 2016 14

Table 3: CMS Reported Program Integrity Contractor Corrective 

Actions and Associated Savings from FPS, Fiscal Years 

(FY) 2015 and 2016 16

Table 4: Healthcare Fraud Prevention Partnership Completed 

Studies as of May 2017 21

Figures

Figure 1: Zone Program Integrity Contractor (ZPIC) and Unified 

Program Integrity Contractor (UPIC) Jurisdictions 7

Figure 2: Program Integrity Contractor Investigation Processes 8

Figure 3: Medicare Claims Processing 11

Contents
Page ii GAO-17-710 CMS Fraud Prevention System

Abbreviations

CMS Centers for Medicare & Medicaid Services

CPI Center for Program Integrity

FPS Fraud Prevention System

HFPP Healthcare Fraud Prevention Partnership

HHS Department of Health and Human Services

HHS OIG Department of Health and Human Services Office of

 Inspector General

IT information technology

MAC Medicare Administrative Contractor

TTP trusted third party

UPIC Unified Program Integrity Contractor

ZPIC Zone Program Integrity Contractor 

This is a work of the U.S. government and is not subject to copyright protection in the 

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without further permission from GAO. However, because this work may contain 

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Page 1 GAO-17-710 CMS Fraud Prevention System

441 G St. N.W.

Washington, DC 20548

August 30, 2017

Congressional Requesters

In fiscal year 2016, Medicare provided health insurance for approximately 

57 million elderly and disabled beneficiaries at a cost of approximately 

$699 billion.1 Since 1990, we have designated Medicare a high-risk 

program because of its size, complexity, and susceptibility to 

mismanagement and improper payments.2 Some improper Medicare 

payments are due to fraud, which involves willful misrepresentation.3

Although the deceptive nature of fraud makes its extent in the Medicare 

program difficult to measure in a reliable way, there have been 

convictions for multimillion dollar schemes defrauding the program.

The Centers for Medicare & Medicaid Services (CMS)—the agency within 

the Department of Health and Human Services (HHS) that administers 

the Medicare program—is responsible for conducting program integrity 

activities intended to reduce fraud, waste, and abuse. CMS uses 

analyses of claims submitted for payment by health care providers as part 

of its program integrity activities. In 2011, CMS implemented a data 

 1

Medicare is the federally financed health insurance program for persons aged 65 and 

over, certain individuals with disabilities, and individuals with end-stage renal disease. 

Medicare Part A covers inpatient hospital services, skilled nursing facility services, some 

home health services, and hospice services. Medicare Part B covers physician and 

hospital outpatient services, and durable medical equipment, prosthetics, orthotics, and 

supplies, among other things. Together, Parts A and B are known as traditional Medicare 

or Medicare fee-for-service. 

2

See GAO, High-Risk Series: Progress on Many High-Risk Areas, While Substantial 

Efforts Needed on Others, GAO-17-317 (Washington, D.C.: Feb. 15, 2017).

3

The Medicare fee-for-service program generally makes payments directly to health care 

providers, such as hospitals and physicians. An improper payment is any payment that 

should not have been made or that was made in an incorrect amount (including 

overpayments and underpayments) under statutory, contractual, administrative, or other 

legally applicable requirements. This includes any payment to an ineligible recipient, any 

payment for an ineligible good or service, any duplicate payment, any payment for a good 

or service not received (except for such payments where authorized by law), and any 

payment that does not account for credit for applicable discounts. Improper payments may 

be a result of fraud, waste, or abuse. Fraud involves an intentional act or representation to 

deceive with the knowledge that the actions or representation could result in gain. 

Whether an act is in fact fraud is a determination that is made through the judicial or other 

adjudicative system. Waste includes overusing services, such as excessive diagnostic 

testing. Abuse involves actions inconsistent with acceptable business or medical 

practices.

Letter
Page 2 GAO-17-710 CMS Fraud Prevention System

analytic system—the Fraud Prevention System (FPS)—that analyzes 

Medicare fee-for-service claims to identify health care providers with 

suspect billing patterns for further investigation and to prevent improper 

payments. Additionally, in 2012, HHS helped establish a public-private 

partnership—the Healthcare Fraud Prevention Partnership (HFPP)—with 

other health care payers, agencies, and organizations to address 

healthcare fraud. One of the key activities of HFPP is analyzing claims 

data pooled from multiple payers, including Medicare, to identify and 

disseminate information within the partnership on providers with suspect 

billing patterns.

You asked us to review CMS’s use of FPS and the activities of HFPP. 

This report examines

1. CMS’s use of FPS to identify and investigate providers suspected of 

potential fraud;

2. the types of payments that have been denied by FPS; and

3. HFPP’s efforts to further CMS’s and payers’ ability to address health 

care fraud.

To examine CMS’s use of FPS to identify and investigate suspect 

providers, we reviewed CMS documents, including CMS reports to 

Congress on FPS’s implementation, statements of work for program 

integrity contractors, and FPS and other CMS information technology (IT) 

system user guides. We interviewed CMS officials and officials from all 

seven Zone Program Integrity Contractors (ZPIC)—the contractors 

responsible for identifying and investigating potential Medicare fraud, 

waste, and abuse—regarding how FPS is used to identify and investigate 

potential fraud.4 CMS is currently in the process of transitioning Medicare 

program integrity contracts from ZPICs to new contract entities, Unified 

Program Integrity Contractors (UPIC), and we interviewed officials from 

the two UPICs in operation as of May 2017.5 We also obtained and 

 4

CMS began implementing ZPICs in 2008 to replace legacy program integrity contractors, 

Program Safeguard Contractors. Program Safeguard Contractors continued to operate in 

one ZPIC jurisdiction— Zone 6—because of protest-related delays with the Zone 6 ZPIC 

contract. We interviewed officials representing the Program Safeguard Contractors that 

operated in Zone 6. For the sake of simplicity, references to ZPICs in this report are 

inclusive of the Zone 6 Program Safeguard Contractors.

5

UPICs combine responsibility for conducting program integrity activities for both the 

Medicare and Medicaid programs. CMS plans to award all UPIC contracts by the end of 

calendar year 2017.
Page 3 GAO-17-710 CMS Fraud Prevention System

analyzed fiscal year 2015 and 2016 data from CMS on the sources of 

ZPIC investigations and the corrective actions and savings associated 

with ZPIC investigations. To assess the reliability of the data, we 

reviewed relevant agency documents, interviewed CMS officials, 

compared the data to published data, and reviewed the data for any 

outliers and obvious errors. We found the data sufficiently reliable for the 

purposes of our study.

To examine the types of payments that have been denied by FPS, we 

obtained information from CMS on the prepayment edits—automated 

controls that compare claim information to Medicare coverage and 

payment policies in order to approve or deny claims—that have been 

implemented in FPS.6 We interviewed CMS officials about how FPS’s 

edits identify and deny payments. We also interviewed officials 

representing Medicare Administrative Contractors (MAC)—the 

contractors that process and pay Medicare fee-for-service claims and, 

along with CMS, are responsible for implementing prepayment edits—

regarding differences between edits in FPS and those in Medicare’s 

claims processing systems. In addition, we obtained data from CMS on 

the number of claims denied by FPS edits and the associated savings for 

fiscal years 2015 and 2016. To assess the reliability of the data, we 

interviewed CMS officials, compared the data to published data, and 

reviewed the data for any outliers and obvious errors. We found the data 

sufficiently reliable for the purposes of our study.

To examine HFPP’s efforts to further CMS’s and payers’ ability to address 

health care fraud, we reviewed CMS and HFPP documents, including 

HFPP study summaries and findings. We interviewed officials from CMS

and the contractors that have administered HFPP about HFPP 

information and data sharing practices. We also interviewed a nongeneralizable selection of HFPP participants that reflect HFPP’s 

membership. We interviewed officials representing 3 private payers, 5 

state agencies, and 4 associations regarding HFPP’s anti-fraud 

collaboration efforts. We selected private payers that offer Medicare 

Advantage plans, state agencies that use data analytic systems or have 

shared data for HFPP studies, and healthcare and healthcare fraud 

specific associations.

 6

References to FPS claim denials refer to both claims that are rejected or denied by the 

system. Claims that are rejected can be corrected and resubmitted, while claims that are 

denied cannot be resubmitted.
Page 4 GAO-17-710 CMS Fraud Prevention System

We conducted this performance audit from April 2016 to August 2017 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

To advance CMS’s efforts to prevent fraud, waste, and abuse in the 

Medicare fee-for service program, the Small Business Jobs Act of 2010 

appropriated $100 million for CMS to implement a data analytic system.7

The law required CMS to implement a system that could analyze claims 

prior to payment to identify suspect claims and provider billing patterns 

and prevent payment of improper and potentially fraudulent claims, 

among other things. In April 2011, CMS awarded almost $77 million to a 

contractor to implement, operate, and maintain FPS and design analytic 

models for the system. CMS awarded about $13 million to a second 

contractor in July 2011 to develop additional analytic models for FPS. As 

the original FPS contract was set to end, CMS awarded a nearly $92 

million contract in April 2016 for a new, upgraded FPS system—FPS 2.0. 

FPS 2.0 was fully implemented in March 2017.

CMS’s Center for Program Integrity (CPI)—which oversees the agency’s 

Medicare program integrity efforts—employs FPS as a key component of 

its strategy to move beyond the “pay and chase” approach of recovering 

improper and potentially fraudulent payments to focusing on prevention. 

FPS screens fee-for-service claims prior to payment in order to help 

identify and prevent improper and potentially fraudulent payments by 

performing two primary functions:

 7

A portion of the appropriated funds was required to be used for an independent 

evaluation of the program. Pub. L. No. 111-240, § 4241(h), 124 Stat. 2504, 2603 (2010) 

(codified at 42 U.S.C. § 1320a-7m(h)). Data analytic systems are IT systems that use a 

variety of techniques to analyze and interpret data to facilitate decision making, and can 

be used to identify patterns or trends. We have previously reported on the importance of 

agencies using data analysis to manage fraud risks. See GAO, A Framework for 

Managing Fraud Risks in Federal Programs, GAO-15-593SP (Washington, D.C.: July 

2015) and GAO, Highlights of a Forum: Data Analytics to Address Fraud and Improper 

Payments, GAO-17-339SP (Washington, D.C.: Mar. 31, 2017).

Background

Fraud Prevention System
Page 5 GAO-17-710 CMS Fraud Prevention System

• Develop leads for fraud investigations. FPS compares provider billing 

patterns and other data against models of potentially fraudulent 

behavior to identify providers with suspect billing patterns. For 

example, an FPS model identifies providers that bill for a 

disproportionate number of services in a single day relative to other 

providers. FPS simultaneously risk-scores providers identified by the 

models to prioritize them for potential investigation. In developing 

these leads, FPS is intended to help CMS prevent potentially 

fraudulent payments by furthering the agency’s ability to more quickly 

identify and investigate suspect providers, and take more timely 

corrective actions.

• Execute automated prepayment edits. FPS edits deny certain 

improper payments, and some edits compare information from 

multiple claims to do so. For example, FPS may deny physician 

outpatient claims based on information from an inpatient claim 

associated with the same episode of care.

CMS submitted three annual reports on FPS’s implementation to 

Congress in response to requirements established by the Small Business 

Jobs Act of 2010. In these reports, CMS provided information on the 

corrective actions taken and savings achieved from FPS.8 In its most 

recent report, CMS reported that FPS had cumulatively helped prevent or 

identify nearly $1.5 billion in improper and potentially fraudulent payments 

from its implementation through the end of calendar year 2015.9

 8

The act further required HHS Office of Inspector General (HHS OIG) to certify the 

reported savings from FPS, and HHS OIG issued companion reports on CMS’s reported 

savings for the first three years of FPS. Although not required by the act to report on FPS 

after the first three years, CMS publicly issued a fourth year report. See 

https://www.cms.gov/About-CMS/Components/CPI/Downloads/Fraud-Prevention-SystemReturn-on-Investment-Fourth-Implementation-Year-2015.pdf 

9

The $1.5 billion figure above includes both payments directly prevented by FPS, such as 

prepayment edit claim denials, and identified savings associated with actions taken 

against providers suspected of fraud, such as the amount of overpayments referred for 

collection. The actual savings achieved is lower because of a number of factors. For 

example, not all referred overpayments can be recovered. CMS applies adjustment 

factors to the identified savings to estimate actual savings from FPS. For instance, while 

CMS reported $454 million in prevented and identified savings from FPS in calendar year 

2014, CMS estimated actual savings of $133 million. For more information on the 

adjustment factors used by CMS, see CMS, Report to Congress Fraud Prevention System 

Second Implementation Year, June 2014.
Page 6 GAO-17-710 CMS Fraud Prevention System

CMS uses contractors to support the agency’s program integrity activities, 

including program integrity contractors to identify and investigate 

providers engaged in potential Medicare fee-for-service fraud. CMS is 

currently in the process of transitioning Medicare program integrity 

contracts from ZPICs to new contract entities, UPICs. ZPICs operated in 

seven geographical jurisdictions across the country. UPICs will operate in 

five jurisdictions and combine Medicare and Medicaid program integrity 

efforts under a single contracting entity (fig. 1 depicts the geographic 

jurisdictions of ZPIC and UPIC zones). As of May 2017, two of the five 

UPICs—the Midwestern and Northeastern—were operational.

Medicare Program 

Integrity
Page 7 GAO-17-710 CMS Fraud Prevention System

Figure 1: Zone Program Integrity Contractor (ZPIC) and Unified Program Integrity Contractor (UPIC) Jurisdictions
Page 8 GAO-17-710 CMS Fraud Prevention System

The program integrity contractors identify leads for provider investigations 

from three categories of sources:

• Referrals. A number of entities, including CMS, law enforcement 

agencies, and the MACs, refer leads about suspect providers to the 

program integrity contractors. The program integrity contractors also 

receive leads based on beneficiary and provider complaints and 

allegations.

• Program integrity contractor data analysis. Program integrity 

contractors use postpayment claims to conduct their own data 

analyses to identify providers with suspect billing patterns.

• FPS. FPS identifies providers with suspect billing patterns and 

prioritizes leads based on provider risk-scores.

The program integrity contractors generally have a triage process to 

review leads and determine whether the leads are indicative of potential 

fraud (see fig. 2 for information on program integrity contractor 

investigation processes). Leads that are determined to be suspect 

become formal investigations, and the program integrity contractors 

perform a range of investigative activities to gather evidence and 

determine if providers are engaged in potential fraud. These activities 

include conducting beneficiary and provider interviews, site visits of 

provider facilities, and manual reviews of provider claims.

Figure 2: Program Integrity Contractor Investigation Processes
Page 9 GAO-17-710 CMS Fraud Prevention System

Based on their investigations, the program integrity contractors may take 

corrective actions by referring providers engaged in potential fraud to law 

enforcement and initiating administrative actions. Specifically, if the 

program integrity contractors uncover evidence of potential fraud, they 

refer the investigation to the Department of Health and Human Services 

Office of Inspector General (HHS OIG) for further examination, which may 

lead to possible criminal or civil prosecution by the Department of Justice. 

The program integrity contractors may also recommend a range of 

administrative actions to CMS for approval and implementation. Such 

actions include revocation of providers’ billing privileges and payment 

suspensions (table 1 describes the administrative actions the program 

integrity contractors may recommend against providers).

Table 1: Administrative Actions Against Medicare Providers That May Result from 

Program Integrity Investigations

Action Definition

Prepayment review Provider-specific prepayment edits that suspend 

payments pending manual claim review.

Provider-specific auto-denial edits Provider-specific prepayment edits that 

automatically deny payments to the provider.

Payment suspension Temporary suspension of provider payments 

pending investigation of potential fraud.

Overpayment determination Referral for collection of provider payments received 

in excess of amounts due and payable.

Revocation Termination of provider’s billing privileges.

Source: GAO analysis of CMS information. | GAO-17-710

CMS’s claims processing systems apply prepayment edits to all Medicare 

fee-for-service claims in an effort to pay claims properly. Most of the 

prepayment edits are automated, meaning that if a claim does not meet 

the criteria of the edit, it is automatically denied. Other prepayment edits 

flag claims for manual review, in which trained clinicians and coders 

examine claims and associated medical records to ensure that the claims

meet Medicare rules and requirements. Many improper and potentially 

fraudulent claims can be identified only by manually reviewing associated 

medical records and beneficiary claim histories, and exercising clinical 

judgment to determine whether services were reasonable and necessary. 

Whereas automated edits are applied to all claims, manual edits are 

applied to very few—less than 1 percent of claims undergo manual 

review.

CMS’s Prepayment Edits 

Process
Page 10 GAO-17-710 CMS Fraud Prevention System

CMS contracts with the MACs to process and pay Medicare fee-forservice claims and implement prepayment edits in the Medicare claims 

processing systems.10 The claims processing systems consist of three 

systems—the MAC front-end systems, shared systems, and Common 

Working File—that carry out a variety of functions and execute 

prepayment edits (see fig. 3). When implementing FPS, CMS integrated 

FPS with the claims processing systems and claims are screened by FPS 

prior to payment. Unlike the claims processing systems, CPI maintains 

FPS.

 10CMS is generally required to pay Medicare claims between 14 and 30 days from the 

date of receipt.
Page 11 GAO-17-710 CMS Fraud Prevention System

Figure 3: Medicare Claims Processing 

a

The shared systems are the Fiscal Intermediary Shared System, Multi-Carrier System, and the ViPS 

Medicare System. The Fiscal Intermediary Shared System processes Part A claims and certain Part 

B claims related to medical care provided by institutional providers, such as hospital inpatient and 

outpatient departments. The Multi-Carrier System processes all other Part B claims, such as 

physician claims. The ViPS Medicare System processes claims for durable medical equipment.

HFPP is a voluntary public-private partnership established by HHS and 

the Department of Justice to facilitate collaboration in addressing 

healthcare fraud. The membership includes Medicare- and Medicaidrelated federal agencies and several state agencies, other federal 

agencies with responsibility for federal health care programs such as the 

Healthcare Fraud 

Prevention Partnership
Page 12 GAO-17-710 CMS Fraud Prevention System

Department of Defense and Department of Veterans Affairs, law 

enforcement agencies, private payers, and antifraud and other healthcare 

organizations. HFPP was established, in part, to help payers identify 

schemes and providers engaged in potential fraud that individual payers 

may not be able to identify alone. HFPP began in 2012 with 20 members 

and, as of June 2017, had grown to 79 members.11 As of the end of 

calendar year 2016, CMS had cumulatively spent $30.3 million on HFPP.

ZPIC officials stated that FPS helps them identify suspect providers 

quickly. Because FPS analyzes claims prior to payment, providers with 

suspect billing patterns can be identified quickly relative to other sources 

of leads. In particular, several ZPIC officials stated that the leads they 

develop from their data analyses of postpayment claims are not as timely. 

Officials from two ZPICs estimated that the postpayment claims they use 

for their analyses may have been for services rendered 1 to 2 months 

prior, while the claims analyzed by FPS may have been for services 

recently rendered.

ZPIC officials also said the information associated with FPS leads allows 

them to examine and triage those leads quickly to determine whether to 

initiate investigations. FPS leads provide specific information about the 

type of potential fraud identified, along with claims data and other 

supporting information. ZPIC officials further stated that they use 

 11In November 2016, HFPP had 70 members and CMS reported that payer participants 

covered approximately 65 percent of covered U.S. individuals. 

CMS Program 

Integrity Contractors 

Reported That FPS 

Speeds Up Certain 

Investigation 

Processes and Has 

Contributed to 

Program Savings

CMS Program Integrity 

Contractors Reported That 

FPS Speeds Up Certain 

Investigation Processes, 

and CMS Is Taking Steps 

to Track Data on 

Timeliness
Page 13 GAO-17-710 CMS Fraud Prevention System

information from FPS when triaging leads from other sources. In contrast 

to FPS leads, several ZPIC officials noted that reviewing and triaging 

leads based on referrals often necessitates additional time and resources. 

In particular, allegations associated with some referrals can be vague, 

which makes it difficult for ZPICs to identify the relevant provider claims 

data and other information needed to assess the validity of the 

allegations.

However, once an investigation is initiated, officials stated that FPS has 

generally not sped up the process for investigating providers. Several 

ZPIC officials noted that investigations based on FPS leads are similar to 

those from other sources in that they require further investigation, such as 

manual claim reviews or site visits of provider facilities, to substantiate the 

leads and gather evidence of potential fraud. However, while ZPIC 

officials said that FPS does not speed up investigations, officials from 

several ZPICs noted that FPS can help improve the quality of beneficiary 

interviews. Since FPS leads are based on prepayment claims data, 

ZPICs can conduct beneficiary interviews shortly after the services have 

been rendered, when beneficiaries may be better able to recall details 

about their care.

CMS has not tracked data to assess FPS’s effect on the timeliness of 

investigation processes.12 CMS has lacked such timeliness data because 

of limitations with its IT system for managing and overseeing ZPICs. 

However, as of May 2017, CMS was in the process of implementing a 

new IT system that could be used to assess FPS’s effect on the 

timeliness of program integrity contractor investigation processes. In 

transitioning to UPICs, CMS is implementing a new contractor workload 

management system that will capture data on the timeliness of UPIC 

investigation processes.13 For example, the system will be able to capture 

information on the amount of time it takes a UPIC to evaluate a lead or 

conduct an investigation. CMS officials said that the agency plans to use 

the information tracked by the system to monitor program performance, 

including assessing FPS’s effect on UPIC investigation processes and the 

 12We previously reported on the importance of tracking the timeliness of program integrity 

contractor investigation processes, since CMS can save money by taking administrative 

actions against providers suspected of fraud more quickly. See GAO, Medicare Program 

Integrity: Contractors Reported Generating Savings, but CMS Could Improve Its 

Oversight, GAO-14-111 (Washington, D.C.: Oct. 25, 2013).

13CMS is replacing the Analysis, Reporting, and Tracking system used by ZPICs with the 

Unified Case Management system for UPICs.
Page 14 GAO-17-710 CMS Fraud Prevention System

timeliness of corrective actions. The officials also stated that they may not 

be able to conduct such an assessment for several years as CMS is still 

in the process of transitioning to UPICs and implementing the new IT 

system. Further, the officials said that they subsequently would want to 

collect several years’ worth of such data to ensure a reliable assessment.

In fiscal years 2015 and 2016, about 20 percent of ZPIC investigations 

were initiated based on FPS leads, according to our analysis (see table 

2). In both years, nearly half of ZPIC investigations were based on 

referrals.

Table 2: Sources of Zone Program Integrity Contractor (ZPIC) Investigations, Fiscal 

Years (FY) 2015 and 2016 

FY 2015 FY 2016

Source of 

investigations

Number of new 

investigations

Percentage 

of workload

Number of new 

investigations

Percentage 

of workload

Referrals 1513 53 1395 47

ZPIC data 

analysis

722 25 937 31

FPS 604 21 654 22

Source: GAO analysis of CMS data. | GAO-17-710

Note: Percentages may not sum to 100 due to rounding.

The proportion of investigations based on FPS leads is poised to increase 

as CMS changes program integrity contractor requirements for using FPS 

with the transition from ZPICs to UPICs. CMS has required the ZPICs to 

review all FPS leads that met high-risk thresholds. CMS is instead 

requiring that the UPICs derive 45 percent of new investigations from 

FPS. ZPIC officials stated that the new UPIC requirement should allow 

UPICs flexibility to focus their reviews on the FPS leads that are most 

applicable to their geographic region. For example, a UPIC with high 

levels of home health agency fraud within its jurisdiction can focus its 

reviews of FPS leads on those providers.14

 14We previously found CMS’s requirement that ZPICs review all FPS leads that met highrisk thresholds created challenges for ZPICs because FPS sometimes prioritized leads 

that targeted fraud schemes that were not prevalent in specific ZPIC zones. See GAO, 

Medicare Fraud Prevention: CMS Has Implemented a Predictive Analytics System, but 

Needs to Define Measures to Determine Its Effectiveness, GAO-13-104 (Washington, 

D.C.: Oct. 15, 2012).

FPS Accounted for About 

20 Percent of 

Investigations in 2015 and 

2016 and Contributed to 

Program Savings
Page 15 GAO-17-710 CMS Fraud Prevention System

Investigations initiated by FPS and existing investigations that were 

supported by FPS have led to corrective actions against providers 

engaged in potential fraud and program savings, based on CMS reported 

data. For example, in fiscal year 2015, nearly 60 percent of providers 

subject to prepayment review and 25 percent of estimated savings from 

prepayment reviews were associated with FPS (see table 3). In fiscal 

year 2016, nearly 25 percent of provider payment suspensions and about 

15 percent of estimated savings from payment suspensions were 

associated with FPS.
Page 16 GAO-17-710 CMS Fraud Prevention System

Table 3: CMS Reported Program Integrity Contractor Corrective Actions and Associated Savings from FPS, Fiscal Years (FY) 

2015 and 2016 

FY 2015 FY 2016

Action Total 

actions

Actions 

associated 

with FPSa

Percentage 

associated 

with FPS

Total 

actions

Actions 

associated 

with FPSa

Percentage 

associated 

with FPS

Number of providers subject 

to prepayment review

546 311 57% 686 446 65%

Estimated savingsb

(dollars in millions)

$59.8 $15.0 25% $54.0 $17.3 32%

Number of providers subject 

to auto-denial editsc — 236 — — 238 —

Estimated savingsb 

(dollars in millions)

$63.4 $1.5 2% $54.5 $1.7 3%

Number of overpayment 

determinations referred for 

collection

876 443 51% 1112 526 47%

Amount referred for 

collection (dollars in 

millions)

$935.7 $291.7 31% $1221.2 $358.8 29%

Estimated savingsd 

(dollars in millions) $175.5 $40.0 23% $178.7 $52.7 29%

Number of providers subject 

to payment suspension during 

the fiscal year

377 55 15% 393 90 23%

Estimated savingse 

(dollars in millions) $49.7 $12.9 26% $46.7 $6.7 14%

Number of providers revoked 441 101 23% 303 45 15%

Number of providers referred 

to law enforcementf — 53 — — 41 —

Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) data. | GAO-17-710

Notes: CMS applies adjustment factors to identified savings amounts to estimate actual savings. For 

more information on the adjustment factors used by CMS, see CMS, Report to Congress Fraud 

Prevention System Second Implementation Year, June 2014.

a

Includes both actions from investigations initiated by the Fraud Prevention System (FPS) and 

existing investigations that were supported or corroborated by FPS.

b

The savings amounts are estimates of what CMS would have paid had the claims been processed, 

and are further adjusted based on the historic rate at which claim denials are overturned on appeal.

c

For the total actions, CMS tracked the number of auto-denial edits implemented. For actions 

associated with FPS, CMS tracked the number of providers subject to auto-denial edits. These data 

are not directly comparable.

d

The savings amounts are estimates based on historic overpayment collection rates, with the 

exception of the total amount collected in FY 2016. Starting in FY 2016, CMS began tracking total 

overpayment savings based on actual amounts collected.

e

The savings amounts are estimates based on the historic rate at which payments held in suspension 

because of program integrity contractor actions are later recouped.
Page 17 GAO-17-710 CMS Fraud Prevention System

f

For total actions, CMS tracked the number of investigations referred to law enforcement. For actions 

associated with FPS, CMS tracked the number of providers referred to law enforcement. These data 

are not directly comparable.

In addition to tracking the corrective actions and savings associated with 

FPS, CMS also measures the extent to which investigations initiated from 

FPS leads result in actions against providers engaged in potential fraud.15

CMS reported that, in fiscal year 2015, 44 percent of FPS-initiated 

investigations resulted in administrative actions, which met the agency’s 

fiscal year goal of 42 percent of investigations leading to administrative 

actions. In fiscal year 2016, 38 percent of FPS-initiated investigations 

resulted in administrative actions, which did not meet the agency’s fiscal 

year goal of 45 percent.

 15CMS developed this measure in response to a prior GAO recommendation that the 

agency develop outcome-based performance goals to measure FPS’s performance. See 

GAO-13-104.
Page 18 GAO-17-710 CMS Fraud Prevention System

FPS prepayment edits screen individual claims to automatically deny 

payments that violate Medicare rules or policies. For example, some FPS 

edits deny claims that exceed coverage utilization limits for a service. 

FPS edits do not analyze individual claims to automatically deny 

payments based on risk alone or the likelihood that they are fraudulent.16

According to CMS officials, the agency does not have the authority to use 

FPS to automatically deny individual claims based on risk without further 

evidence confirming that the claims are potentially fraudulent.17

Although the prepayment edits in FPS are functionally similar to those in 

CMS’s claims processing systems, the FPS edits specifically target 

payments associated with potential fraud schemes. Like edits executed 

elsewhere in the claims processing systems, FPS edits deny payments 

based on rules or policies. Unlike the edits in the claims processing 

systems, all of the edits in FPS are designed to address identified 

payment vulnerabilities associated with potential fraud, according to CMS 

officials. Payment vulnerabilities are service- or system-specific 

weaknesses that can lead to improper payments, including improper 

payments that may be due to fraud. For example, CMS implemented an 

FPS edit that denies physician claims that improperly increase payments 

by misidentifying the location that the service was rendered. The 

payments are denied based on the rule that physician claims must 

correctly identify the place of service. The edit helped address a payment 

 16We previously analyzed the use of analytic systems by health care payers and did not 

identify any payers that use analytic systems to automatically deny individual claims 

based on the likelihood that they are fraudulent. See GAO-13-104. 

17CMS may suspend payment based on reliable information of an overpayment, or 

pending an investigation of a credible allegation of fraud as determined in consultation 

with HHS OIG. 42 U.S.C. § 1395y(o); 42 C.F.R. § 405.371 (2016). CMS program integrity 

activities intended to address fraud generally do not focus on reviewing whether individual 

payments are potentially fraudulent, but instead focus on identifying suspect billing 

patterns and taking action against providers engaged in potential fraud. Payment denials 

of potentially fraudulent claims generally stem from investigations into or corrective actions 

taken against providers, such as payments denied for providers subject to prepayment 

review.

FPS Denies 

Payments Based on 

Medicare Rules or 

Policies and Not 

Fraud Risk
Page 19 GAO-17-710 CMS Fraud Prevention System

vulnerability identified by HHS OIG that found millions of dollars in 

overpayments.18

According to CMS officials, the advantage of using FPS to implement 

prepayment edits is that the system allows CMS to prioritize edits 

intended to address payment vulnerabilities associated with potential 

fraud. Because CPI maintains FPS, CMS can quickly implement edits into 

FPS. In contrast, edits that are implemented in the claims processing 

systems are queued as part of quarterly system updates, and may need 

to compete with other claims processing system updates. CPI is not 

subject to such limitations when implementing edits in FPS, and officials 

said that edits can be developed and implemented in FPS more quickly 

compared to the claims processing systems.

As of May 2017, CMS had implemented 24 edits in FPS. CMS reported 

that in fiscal year 2015, FPS edits denied nearly 169,000 claims and 

saved $11.3 million. In fiscal year 2016, the edits denied nearly 324,000 

claims and saved $20.4 million.19 CMS officials stated that the number of 

prepayment edits implemented in FPS thus far has been limited, but that 

the agency is taking steps to address certain challenges that would allow 

the agency to develop and implement edits more quickly. For example, 

because of their role and expertise in processing claims, the MACs 

advise CPI and help develop and test FPS edits before they are 

implemented in the system to ensure they will work as intended. 

However, CPI has been limited in the amount of MAC resources that it 

can engage to help develop FPS edits under existing contracts. 

According to officials, CPI is planning to take steps to more directly 

involve the MACs in FPS edit development, which officials said should 

accelerate the edit implementation process. Additionally, CMS officials 

 18Medicare payments to physicians account for overhead expenses. HHS OIG found 

physician claims for services performed at facility locations, such as ambulatory surgical 

centers, that were billed as if they had been performed at physician offices. This resulted 

in overpayments to physicians for office overhead expenses. See Department of Health 

and Human Services Office of Inspector General, Incorrect Place-of-Service Claims 

Resulted in Potential Medicare Overpayments Costing Millions, A-01-13-00506 

(Washington, D.C.: May 2015).

19As of the end of fiscal year 2016, CMS had implemented 17 edits, and officials told us 

that 7 additional edits have since been added. CMS reported that in fiscal year 2015, FPS 

edits denied $17.5 million and, in fiscal year 2016, denied $33.6 million. The savings data 

above excludes payments associated with denied claims that were later corrected, 

resubmitted, and paid, and amounts associated with resubmitted claims that were again 

denied by FPS.
Page 20 GAO-17-710 CMS Fraud Prevention System

said that they plan to utilize FPS functionality to implement new edits by 

expanding existing edits to apply to other services. All of the 24 current 

FPS edits were developed from the ground up, a time and resource 

consuming process, according to CMS officials. In contrast, developing 

new edits by expanding existing edits will allow CMS to more quickly 

develop and implement new edits.

HFPP participants we interviewed, including CMS officials, reported that 

sharing data and information within HFPP has been useful to their efforts 

to address health care fraud. The principal activity of HFPP is generating 

studies that pool and analyze multiple payers’ claims data to identify 

providers with patterns of suspect billing across multiple payers. Study 

topics examine known fraud vulnerabilities important to the participating 

payers and are selected through a collaborative process. As an example, 

one study used pooled data to identify providers who were cumulatively 

billing multiple payers for more services than could reasonably be 

rendered in a single day. In another study, HFPP pooled payer 

information on billing codes that are frequently misused by providers 

engaged in potential fraud, such as codes commonly used to 

misrepresent non-covered services as covered. See table 4 for a 

description of HFPP’s completed studies as of May 2017.

Participants Reported 

That HFPP Efforts 

Furthered Their Ability 

to Address Health 

Care Fraud

Participants Reported That 

Information Sharing 

through HFPP Furthered 

Efforts to Address Fraud
Page 21 GAO-17-710 CMS Fraud Prevention System

Table 4: Healthcare Fraud Prevention Partnership Completed Studies as of May 

2017

Study Description

Misused Codes and Fraud 

Schemes

A pooled list of approximately 1400 misused codes 

and 100 fraud schemes.

Non-Operational Providers A pooled list of providers that have been found to be 

non-operational, such as false store fronts, and only 

exist on paper to file claims for services that were 

never rendered. 

Revoked/Terminated Providers A pooled list of provider organizations that have been 

revoked or terminated by payers for reasons relating 

to fraud, waste, and abuse.

Top Billing Pharmacies for 

Controlled Prescription Drugs

An analysis identifying the billing pharmacies with 

extreme outlier dispensing of controlled prescription 

drugs.

Urine Drug and Genetic Testing 

Referrals

An analysis identifying providers with unusual referral 

patterns for urine drug and genetic testing.

Psycho-Therapy Timed Code 

Analysis

An analysis of behavioral health providers identifying 

those who may be cumulatively billing multiple payers 

for more services than could reasonably be rendered 

in a single day.

Source: GAO analysis of CMS information. | GAO-17-710

Participants reported that HFPP’s studies helped them to identify and 

take action against potentially fraudulent providers that would otherwise 

have gone unidentified. For instance, both public and private payers 

reported that HFPP’s non-operational providers report uncovered 

providers that they had not previously identified as suspect. CMS officials 

and one private payer we interviewed said that they used information 

from this study to conduct site visits of reportedly non-operational 

providers. CMS officials told us that they revoked a number of the 

providers after confirming that they were indeed non-operational. CMS 

officials also said that they review the results of HFPP studies and 

provide information on potentially fraudulent providers to ZPICs when 

appropriate. The information may either serve as new leads or help 

support existing investigations.

Participants also reported that study results have helped them uncover 

payment vulnerabilities of which they might not otherwise have been 

aware. For example, CMS officials stated that they used the HFFP report 

on misused procedure codes to evaluate several Medicare payment 

vulnerabilities and then implemented edits to address them. In instances 

where participants reported that HFPP studies revealed suspect providers 

or schemes that were known to them, participants stated that HFPP study 
Page 22 GAO-17-710 CMS Fraud Prevention System

results helped them to confirm suspicions, better assess potential 

exposure, and prioritize and develop internal investigations.

Several participants we interviewed noted that even though HFPP study 

results can help them identify suspect providers, they may still face 

challenges using the information to take corrective actions. HFPP 

participation rules require payers to examine their internal data and 

claims to investigate and build cases against suspect providers before 

taking any corrective actions, partly in order to minimize the risk of payers 

taking action on false positive study results. For certain types of fraud 

schemes, however, the participants’ internal information alone may not 

provide enough evidence of improper billing. For instance, although an 

HFPP study may reveal clear evidence that a provider is billing multiple 

payers for an unreasonable number of services in a single day, the 

provider may have only billed individual payers for a limited, reasonable 

number of services.

Participants reported that HFPP has also facilitated both formal and 

informal information sharing among payers, and indicated that it has 

helped them learn about fraud vulnerabilities and strategies for effectively 

addressing them. Formal information sharing includes presentations at 

HFPP meetings and a whitepaper on how payers can help address 

beneficiary opioid abuse and reduce opioid-related fraud.20 HFPP also 

manages a web portal where participants can share individual best 

practices and post “fraud alerts” about emerging fraud schemes or 

suspect providers. Informal information sharing includes knowledge 

exchanged through the networking and collaboration that occurs among 

HFPP participants, both at in-person HFPP meetings and through 

collaboration that occurs via the web portal’s participant directory.

 20See HFPP and NORC, Healthcare Payer Strategies to Reduce the Harms of Opioids, 

(January 2017), accessed February 6, 2017, https://downloads.cms.gov/files/hfpp/hfppopioid-white-paper.pdf.
Page 23 GAO-17-710 CMS Fraud Prevention System

Although HFPP began operations in 2012, participants we interviewed 

stated that much of the initial work of the partnership involved negotiating 

the logistics for collecting and storing participants’ claims data. CMS 

contracts with a trusted third party (TTP) entity to administer HFPP. The 

TTP consolidates, secures, and confidentially maintains the claims data 

shared by participants, and conducts studies that analyze the pooled data 

to identify potential fraud across payers. According to several participants 

we interviewed, some payers were initially reluctant to share claims data 

with the TTP because claims contain sensitive provider and beneficiary 

information and private payers may view them as proprietary. 

Accordingly, it took time for the TTP to demonstrate to payers its ability to 

securely store and use pooled claims data. Payers’ reluctance resulted in 

an early time- and resource-intensive data sharing strategy that relied 

upon payers submitting a limited amount of claims data on a study-bystudy basis, in a particular format, stripped of beneficiaries’ personally 

identifiable information and protected health information.

Recently, HFPP began to pursue a new data sharing strategy. According 

to the TTP and participants we interviewed, payers will send in 

generalized data, reducing the data sharing burden on payers and 

enabling HFPP to conduct new types of studies to combat fraud. The data 

can be submitted in various formats, relieving payers from the need to 

extract and clean study-specific data. All participant data will be pooled 

and stored, and multiple studies will be run on the data submitted. Payers 

may voluntarily submit data that includes beneficiaries’ personally 

identifiable information and protected health information. According to 

CMS officials, collection of personally identifiable information and 

protected health information will allow HFPP to conduct studies that 

involve identifying beneficiaries across payers, such as studies examining 

fraud schemes in which multiple providers fraudulently bill for the same 

beneficiaries.21

Several HFPP participants we spoke with indicated their support of the 

new strategy and willingness to provide beneficiaries’ personally 

identifiable information and protected health information for more in-depth 

HFPP studies. As of May 2017, 38 partners had signed data sharing 

agreements with the new TTP. However, not all payers that previously 

 21CMS officials stated that beneficiary data will be de-identified by assigning beneficiaries 

HFPP-specific identification numbers. The de-identified beneficiary data will be stored for 

a period of time appropriate to conduct multiple studies.

HFPP Addressed Initial 

Data Sharing Concerns 

and Is Pursuing a New 

Data Sharing Strategy to 

Further Participants’ Ability 

to Address Fraud
Page 24 GAO-17-710 CMS Fraud Prevention System

shared claims data have agreed to participate in the new data sharing 

strategy and those payers are still working with the TTP to formalize 

agreements regarding how their claims data will be stored and used.

GAO provided a draft of this report to HHS. HHS provided technical 

comments, which GAO incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Secretary of Health 

and Human Services, the Administrator of CMS, appropriate 

congressional requesters, and other interested parties. In addition, the 

report will be available at no charge on the GAO website at 

http://www.gao.gov.

If you or your staff members have any questions about this report, please 

contact me at (202) 512-7114 or at kingk@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff that made key contributions to this 

report are listed in appendix I.

Kathleen M. King

Director, Health Care

Agency Comments
Page 25 GAO-17-710 CMS Fraud Prevention System

List of Requesters

The Honorable Greg Walden

Chairman

The Honorable Frank Pallone

Ranking Member

Committee on Energy and Commerce

House of Representatives

The Honorable Kevin Brady

Chairman

Committee on Ways and Means

House of Representatives

The Honorable Michael C. Burgess

Chairman

The Honorable Gene Green

Ranking Member

Subcommittee on Health

Committee on Energy and Commerce

House of Representatives

The Honorable Tim Murphy

Chairman

The Honorable Diana DeGette

Ranking Member

Subcommittee on Oversight and Investigations

Committee on Energy and Commerce

House of Representatives

The Honorable Patrick J. Tiberi

Chairman

The Honorable Sander Levin

Ranking Member

Subcommittee on Health

Committee on Ways and Means

House of Representatives
Page 26 GAO-17-710 CMS Fraud Prevention System

The Honorable Vern Buchanan

Chairman

The Honorable John Lewis

Ranking Member

Subcommittee on Oversight

Committee on Ways and Means

House of Representatives

The Honorable Peter Roskam

House of Representatives

The Honorable Fred Upton

House of Representatives
Appendix I: GAO Contact and Staff 

Acknowledgments

Page 27 GAO-17-710 CMS Fraud Prevention System

Kathleen M. King, (202) 512-7114, kingk@gao.gov

In addition to the contact named above, Martin T. Gahart (Assistant 

Director), Michael Erhardt (Analyst-in-Charge), Muriel Brown, Cathleen 

Hamann, Colbie Holderness, and Jennifer Whitworth made key 

contributions to this report.

Appendix I: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100812)
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