On Feb. 5, 2017 President Trump’s nominee to be secretary of Health and Human Services (HHS), Representative Tom Price (R-GA), was confirmed by the Senate. What will his appointment mean in the government’s battle to thwart healthcare fraud and abuse?

A report by the Journal of Emergency Medical Services reports “We do not expect the federal government’s scrutiny of healthcare reimbursement to diminish under the Trump administration and Secretary Price, but the focus on how to accomplish that scrutiny may shift.”

When asked by Senator Orrin Hatch (R-UT) what he believed HHS [which includes the Centers for Medicare and Medicaid Services (CMS)] should be doing in the fight against fraud and abuse, Price said he felt that the focus should be more on going after the truly “bad actors” and that it should be done “in real time.”

This was direct reference to CMS’ data analytics approach and data mining that is now beginning to be used to identify outliers and those providers who stick out among their peers as potentially billing particular payment codes improperly or excessively.

This effectively moves away from the “pay and chase” model that has been the hallmark of Medicare audits – pay the claims and then do a post-payment audit. The more recent data-driven approach to identify improper billing makes good sense when comparing similar health providers with similar lines of service.

Price then went on to say this data analytics approach should be used “instead of trying to determine if every single instance of care was necessary,” – a direct reference to the current practice of CMS contractors that finds fault in claims for failure to meet medical necessity requirements.

That is why, in great part, there is such a backlog of Medicare appeals stuck at the administrative law judge level – improper medical necessity determinations made at the lower levels of appeal by the very Medicare contractors that pay the claims.