New Bill Aims to Harness AI for DME Payment Oversight
The Medicare Transaction Fraud Prevention Act sets out to decrease fraud & abuse in the Medicare system
By Michelle Love
On June 12, a bill was introduced to Congress to amend title XI of the Social Security Act. The Medicare Transaction Fraud Prevention Act (S 2066) aims to establish a two-year pilot program to test the use of a predictive risk-scoring artificial intelligence (AI) algorithm to provide oversight of payments for durable medical equipment (DME) and clinical diagnostic laboratory tests under the Medicare program.
S 2066 was introduced in the Senate by Sens. Eric Schmitt (R-MO), Maggie Hassan (D-NH) and Tim Sheehy (R-MT).
BILL HIGHLIGHTS
- The AI algorithm would assign a risk score to all fee-for-service (FFS) transactions and that would then be sent to the Inspector General’s office.
- The algorithm would learn from beneficiary data to score relevant transactions from one (least risky) to 99 (most risky).
- High risk scores are for claims billed at a rate or style deemed irregular.
- The bill said this would allow human inspectors to prioritize reviews of transactions most likely to be fraudulent.
- Medicare beneficiaries can opt in to the program, so Medicare payment data is only obtained by the pilot with consent.
- For purposes of identifying and calculating the risks of relevant transactions under the pilot program, the Secretary may consider the following factors:
- The absence of a prior relationship between the beneficiary and a provider of services or supplier
- Aberrant billing patterns for a provider of services or supplier with regard to the volume of claims in one particular area
- Electronic fund transfer (EFT) changes
- Changes in ownership of a provider of services or a supplier
Comments from the Senators
“Artificial intelligence has set our nation at the precipice of the next great American revolution, and harnessing AI’s power to identify potential waste, fraud and abuse will help strengthen the Medicare system for those who depend on it and ensure our taxpayer dollars are being well spent. I’m glad to lead this bipartisan bill to utilize cutting-edge technology to help America’s seniors and protect Medicare benefits.” — Sen. Eric Schmitt
“New technologies allow for innovative ways to root out waste, fraud, and abuse and safeguard taxpayer dollars. This bipartisan bill takes a common-sense approach to protecting seniors and Medicare as a whole by identifying waste, fraud and abuse in the system while also providing appropriate privacy protections, human review and protection of the benefits that seniors have paid into and deserve.” — Sen. Maggie Hassan
“The best thing we can do to protect the critical resources Americans rely on, and shore up programs like Medicare, is root out fraud, waste and abuse. We must strengthen Medicare for the people that really need it, and that’s exactly what this bill does by combating Medicare transaction fraud to better protect Americans’ hard-earned money and ensure every taxpayer gets a better return on their investment.” — Sen. Tim Sheehy
To read the full bill, click here.
Michelle Love is associate editor for HomeCare Media.
