stallation of software in multiple informa-
tion technology infrastructures (and data 
facilities); 
(iii) provide access to the best and lat-
est software without the need for upgrades, 
data security, and costly installations; 
(iv) permit modifications to the soft-
ware and system edits in a rapid and time-
ly manner; 
(v) ensure that all technology and de-
cision components reside within the mod-
ule; and 
(vi) ensure that the third party host 
of the modular solution is not a party, 
payer, or stakeholder that reports claims 
data, accesses the results of the fraud pre-
vention systems analysis, or is otherwise 
required under this section to verify, re-
search, or investigate the risk of claims. 
(C) PROCESSING, SCORING, AND
STOR-
AGE.—The platform of the fraud prevention 
system shall be a high volume, rapid, real-time 
information technology solution, which includes 
data pooling, data storage, and scoring capabili-
ties to quickly and accurately capture and 
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evaluate data from millions of claims per day. 
Such platform shall be secure and have (at a 
minimum) data centers that comply with Fed-
eral and State privacy laws. 
(D) DATA CONSORTIUM.—The fraud pre-
vention system shall provide for the establish-
ment of a centralized data file (referred to as 
a ‘‘consortium’’) that accumulates data from all 
government 
health 
insurance 
claims 
data 
sources. Notwithstanding any other provision of 
law, Federal health care payers shall provide to 
the consortium existing claims data, such as 
Medicare’s ‘‘Common Working File’’ and Med-
icaid claims data, for the purpose of fraud and 
abuse prevention. Such accumulated data shall 
be transmitted and stored in an industry stand-
ard secure data environment that complies with 
applicable Federal privacy laws for use in build-
ing medical waste, fraud, and abuse prevention 
predictive models that have a comprehensive 
view of provider activity across all payers (and 
markets). 
(E) MARKET VIEW.—The fraud prevention 
system shall ensure that claims data from Fed-
eral health programs and all markets flows 
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through a central source so the waste, fraud, 
and abuse system can look across all markets 
and geographies in health care to identify fraud 
and abuse in Medicare, Medicaid, the State 
Children’s Health Program, TRICARE, and the 
Department of Veterans Affairs holistically. 
Such cross-market visibility shall identify un-
usual provider and patient behavior patterns 
and fraud and abuse schemes that may not be 
identified by looking independently at one Fed-
eral payer’s transactions. 
(F) BEHAVIOR ENGINE.—The fraud pre-
vention system shall ensure that the technology 
used provides real-time ability to identify high- 
risk behavior patterns across markets, geog-
raphies, and specialty group providers to detect 
waste, fraud, and abuse, and to identify pro-
viders that exhibit unusual behavior patterns. 
Behavior pattern technology that provides the 
capability to compare a provider’s current be-
havior to their own past behavior and to com-
pare a provider’s current behavior to that of 
other providers in the same specialty group and 
geographic location shall be used in order to 
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provide a comprehensive waste, fraud, and 
abuse prevention solution. 
(G) PREDICTIVE MODEL.—The fraud pre-
vention system shall involve the implementation 
of a statistically sound, empirically derived pre-
dictive modeling technology that is designed to 
prevent (versus post-payment detect) waste, 
fraud, and abuse. Such prevention system shall 
utilize historical transaction data, from across 
all Federal health programs and markets, to 
build and re-develop scoring models, have the 
capability to incorporate external data and ex-
ternal models from other sources into the health 
care predictive waste, fraud, and abuse model, 
and provide for a feedback loop to provide out-
come information on verified claims so future 
system enhancements can be developed based 
on previous claims experience. 
(H) CHANGE CONTROL.—The fraud pre-
vention system platform shall have the infra-
structure to implement new models and at-
tributes in a test environment prior to moving 
into a production environment. Capabilities 
shall be developed to quickly make changes to 
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models, attributes, or strategies to react to 
changing patterns in waste, fraud, and abuse. 
(I) SCORING ENGINE.—The fraud preven-
tion system shall identify high-risk claims by 
scoring all such claims on a real-time capacity 
prior to payment. Such scores shall then be 
communicated to the fraud management system 
provided for under subparagraph (J). 
(J) FRAUD
MANAGEMENT
SYSTEM.—The 
fraud prevention system shall utilize a fraud 
management system, that contains workflow 
management and workstation tools to provide 
the ability to systematically present scores, rea-
son codes, and treatment actions for high-risk 
scored transactions. The fraud prevention sys-
tem shall ensure that analysts who review 
claims have the capability to access, review, and 
research claims efficiently, as well as decline or 
approve claims (payments) in an automated 
manner. Workflow management under this sub-
paragraph shall be combined with the ability to 
utilize principles of experimental design to com-
pare and measure prevention and detection 
rates between test and control strategies. Such 
strategy testing shall allow for continuous im-
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