Public-private partnership to root out healthcare fraud

July 26, 2012 in Medical Technology

WASHINGTON – The Obama Administration has launched what it calls a “ground-breaking partnership” among the federal government, state officials, leading private health insurance organizations, and other healthcare anti-fraud groups to prevent healthcare fraud.

This voluntary, collaborative arrangement uniting public and private organizations is the next step in the government’s efforts to combat healthcare fraud and safeguard health care dollars to better protect taxpayers and consumers, said Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder in their announcement on July 26.

[See also: Sebelius, Holder put spotlight on fight against Medicare fraud]

The partnership builds on existing tools provided by the Affordable Care Act, resulting in: 

  • Tougher sentences for people convicted of health care fraud. Criminals will receive 20 to 50 percent longer sentences for crimes that involve more than $1 million in losses;
  • Enhanced screenings of Medicare and Medicaid providers and suppliers to keep fraudsters out of the program.
  • Suspended payments to providers and suppliers engaged in suspected fraudulent activity.

The administration’s efforts to date have already resulted in a record-breaking $10.7 billion in recoveries of healthcare fraud over the last three years.

The partnership is designed to share information and best practices in order to improve detection and prevent payment of fraudulent healthcare billings. Its goal is to reveal and halt scams that cut across a number of public and private payers, Sebelius said. It will enable those on the front lines of industry anti-fraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders.  It will help law enforcement officials to more effectively identify and prevent suspicious activities, better protect patients’ confidential information and use the full range of tools and authorities provided by the Affordable Care Act and other essential statutes to combat and prosecute illegal actions.

[See also: Government puts analytics to work on Medicare fraud]

The government’s anti-fraud efforts are underpinned by information technology and analytics.

 “This partnership puts criminals on notice that we will find them and stop them before they steal healthcare dollars,” said Sebelius.  “Thanks to this initiative today and the anti-fraud tools that were made available by the healthcare law, we are working to stamp out these crimes and abuse in our health care system.”
 One innovative objective of the partnership, she said, is to share information on specific schemes, utilized billing codes and geographical fraud hotspots so that action can be taken to prevent losses to both government and private health plans before they occur. Another potential goal of the partnership is the ability to spot and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities. A potential long-range goal is to use sophisticated technology and analytics on industry-wide healthcare data to predict and detect healthcare fraud schemes.

“This partnership is a critical step forward in strengthening our nation’s fight against healthcare fraud,” said Holder.  “This Administration has established a record of success in combating devastating fraud crimes, but there is more we can and must do to protect patients, consumers, essential health care programs, and precious taxpayer dollars.”

Bringing additional healthcare industry leaders and experts into this work, he said, would make it possible to act more quickly and effectively.

The Executive Board, the Data Analysis and Review Committee, and the Information Sharing Committee will hold their first meeting in September.  Until then, several public-private working groups will continue to meet to finalize the operational structure of the partnership and develop its draft initial work plan.
A list of the participating agencies and organizations is on the next page.

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