By NextBestFitPhase 5: Stabilize & govern · Step 5.2
Run program integrity & fraud control
Year 1 onward · UHA Program Integrity; HHS-OIG; DOJDiscuss this step
Every concrete action this step requires, who is responsible, and when it happens relative to enactment.
| # | Action | Owner | When | Trade-off |
|---|---|---|---|---|
| 5.2.1 | Real-time predictive analytics on every claim (extending Medicare's Fraud Prevention System). | UHA | Year 1+ | Real-time analytics catch fraud early but can delay legitimate claims with false positives. |
| 5.2.2 | Prepayment review for high-risk categories (DME, hospice, lab, home health, behavioral-health outpatient), which have been Medicare's biggest fraud areas. | UHA | Year 1+ | Prepayment review targets high-risk categories but slows payments to honest providers. |
| 5.2.3 | Publish improper-payment rates by provider type annually; target below 3%. | UHA / OIG | Annual | Publishing improper-payment rates promotes accountability but supplies ammunition to critics. |
| 5.2.4 | Whistleblower rewards under the False Claims Act. | DOJ | Ongoing | Whistleblower rewards uncover fraud but encourage some low-merit claims. |