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Title page 1

Contents 3

Highlights 2

Letter 5

Background 9

Medicare Program Integrity Activities 9

Unified Program Integrity Contractors 10

Key Medicare Fraud Statutes and Mechanisms for Committing Medicare Fraud 11

Fraud Risk Management 13

Medicare Supplemental Payers 15

Characteristics of Medicare Fraud Schemes Include Inappropriate Use of Billing Privileges and Beneficiary Identifiers 16

CMS Uses Data Analytics to Identify Anomalous Billing Patterns and Inform Actions Aimed at Preventing Potentially Fraudulent Payments 21

CMS Uses Data Analytics to Identify Anomalous Billing Patterns Indicative of Fraud 21

CMS Uses Data Analytics to Inform Administrative Actions Aimed at Preventing Potentially Fraudulent Payments 24

CMS Monitors Leads from FPS Models and Associated Administrative Actions to Update Models 26

CMS Has Begun to Inform Supplemental Payers of Payment Suspensions 26

CMS Estimates It Prevented Billions in Potentially Fraudulent Payments from 2022 through 2024 29

Agency Comments 31

Appendix I. Objectives, Scope, and Methodology 32

Appendix II. Medicare Fraud and Accountable Care Organizations 35

Appendix III. Administrative Actions and Potentially Fraudulent Payments Prevented by CMS, Fiscal Years 2022 through 2024 37

Appendix IV. GAO Contacts and Staff Acknowledgments 39

Tables 3

Table 1. Examples of Data Analytic Models Employed by CMS to Identify Potential Medicare Fraud 23

Table 2. Medicare Administrative Actions 24

Table 3. CMS Administrative Actions and Estimates of Potentially Fraudulent Payments Prevented, Fiscal Years 2022 through 2024 30

Table 4. Number of Providers or Referrals Associated with CMS Administrative Actions, by Year, Fiscal Years 2022 through 2024 37

Table 5. CMS Estimates of Potentially Fraudulent Payments Prevented, by Administrative Action and Year, Fiscal Years 2022 through 2024 38

Figures 4

Figure 1. Unified Program Integrity Contractor Investigation Process 10

Figure 2. GAO's Fraud Risk Management Framework 14

Figure 3. Medicare Supplemental Payments 16

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