Medicare Telehealth Program Integrity System

National Framework for Detecting and Preventing Improper Billing in Federal Healthcare Programs

$31.70B
Annual Medicare Improper Payments
7.66%
FY 2024 Improper Payment Rate
88x
Telehealth Usage Increase During COVID
1,714
High-Risk Providers (HHS OIG)

KEY PERFORMANCE INDICATORS

91.3%
Accuracy
100%
Precision
42.0%
Recall
59.0%
F1 Score
0.94
AUC Score

MODEL VALIDATION RESULTS

Method Result Status
Temporal Stability Test 92.0% PASS
False Positive Rate (Critical) 0.0% OPTIMAL
Cross-validation (k-fold=10) 91.3% ± 2.4% PASS
Bootstrap Analysis (n=1000) 95% CI Stable PASS

IMPLEMENTATION ROADMAP

Phase I
Years 1-2
$1.5-3B annually (top 1%)
$6-9B (top 5%)
Phase II
Years 3-5
$8-14B annual savings
$40-50B cumulative
Phase III
Years 5+
$25-30B annually
$150-200B over decade

FINANCIAL IMPACT PROJECTIONS

Implementation Phase Investment Potential Benefit ROI
Pilot Demonstration ~$150,000 $420.2M identified ~42:1
National Deployment (Year 1) ~$10 million $12.6B potential annual ~126:1
5-Year Program ~$200 million total $63B cumulative ~630:1

RISK SCORING COMPONENTS

HIGH-RISK SPECIALTIES IDENTIFIED

Family Practice Hematology-Oncology Clinical Laboratory Pharmacy

TECHNICAL PERFORMANCE

Processing Speed 148 records/second
Memory Usage 2.5 GB
Total Processing Time 5 minutes 47 seconds
Dataset Size 50,000 providers
Service Volume 322.4 million services

DATA SOURCES

  • • CMS Provider Utilization Database
  • • NPPES Registry (1.1M providers)
  • • OIG LEIE Exclusion Lists
  • • PECOS Enrollment Data
  • • Medicare Part B Claims (2019-2023)

VALIDATION METRICS

Temporal Stability

• Temporal Stability Test: 92.0% PASS
• Pattern consistency: 2019-2023
• Detection patterns remain valid

Geographic & Peer Alignment

• Geographic Adjustment: +10 points
• DOJ Strike Force alignment
• False Positive Rate: 0.0%
$12.6B - $30B ANNUALLY
Identified $420.2M in excess payments from 35 high-risk providers (0.07% of sample). National deployment could prevent $12.6B annually in improper billing, with $63B over 5 years. Cross-program expansion to Medicaid, TRICARE, and VA systems projects $25-30B annual prevention and $150-200B over a decade.