Medicare and Data Analytics

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The Centers for Medicare & Medicaid Services (CMS) reported that the use of data analytics in the Medicare program has resulted in millions of dollars in cost avoidance savings and recoveries. Combining relevant data with the right analytical and interpretive tools can assist not only CMS, but providers in identifying improper claims before the payments are made and identifying preventable expenses.

Data analytics consist of a variety of techniques to analyze and interpret data. Two common techniques are predictive data analytics and data mining. Predictive analytics can identify fraud and errors before payments are made. For example, this model analyzes historical provider data to see if it matches the pattern of a known scheme. Data mining can assist in the identification of improper payments after the fact. Data mining involves the application of database technology and techniques, such as statistical modeling to uncover hidden patterns and subtle relationships in data and to infer rules that allow for the prediction of future results. Data analytics can be a powerful tool for providers that work with Medicare risk contracts, since it would help them protect their integrity and the honesty of their practices.

Advantages of using data analytics include a positive return on investment that can exceed that of traditional methods, the ability to garner information used to identify past improper claims and prevent future improper payments, and strengthening existing anti-fraud strategies. Providers can use the information gained from the data analytic techniques to put more effective edits and prior authorization requirements into place, develop new and more effective models to avoid audits and recoveries, and develop more effective use of the resources to generate more revenue.

Providers can also use new emerging data analytics software’s, such as Ensure Data Solutions, to promote targets for intervention, identify best practices, maximize efficiencies and increase profitability. Providers should invest in data analytics and set ground rules to match the data analysis method and purpose.

To implement a data analytics system for provider integrity purposes, providers may want to consider a software like Ensure that integrates CMS guidance.

CMS guidance suggests factors that must be considered, but are not limited to what information will be actionable for the organization, Ensure Data Solutions through its software can support the type of data analysis desired, with a flat cost that includes implementation, licenses, training, and support.

For more CMS guidance visit