Fraud prevention aim of partnership between government, insurers, associations

Author(s):

Insurers, associations, and governmental agencies are joining forces to fight healthcare fraud. Discover the groups involved and what the effort means to you.

Cross your Ts and dot your Is. A new public-private partnership among the federal government, state governments, insurers, professional associations, and anti-fraud groups is expanding nationwide efforts to detect and prevent payment of fraudulent healthcare billings.

“This partnership puts criminals on notice that we will find them and stop them before they steal healthcare dollars,” says Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services (HHS). “Thanks to this initiative…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 healthcare system.”

The partnership's executive board, data analysis and review committee, and information sharing committee will hold their first meetings in September. Until then, several working groups will meet to finalize the operational structure of the group and develop its draft initial work plan.

According to HHS, the effort builds on existing tools provided by the Affordable Care Act, meaning that:

If you provide care to patients receiving Medicare or Medicaid assistance, you will be asked to undergo enhanced screening.

Payments to you will be suspended if you are suspected of engaging in fraudulent activity.

If you’re found to be guilty of fraud involving more than $1 million in losses, you will receive a 20% to 50% longer sentence than you previously would have received.

Specifically, the partnership will try to:

share information on specific schemes, utilized billing codes, and geographic fraud hotspots so that action can be taken to prevent losses to both government and private health plans before they occur;

spot and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities; and;

use sophisticated technology and analytics on industry-wide healthcare data to predict and detect healthcare fraud schemes.

The following insurance companies, associations, and government agencies are among the first to join the initiative:

America’s Health Insurance Plans,

Amerigroup Corp.,

Blue Cross and Blue Shield Association,

Blue Cross and Blue Shield of Louisiana,

Centers for Medicare and Medicaid Services,

Coalition Against Insurance Fraud,

Federal Bureau of Investigations,

Health and Human Services Office of Inspector General,

Humana Inc.,

Independence Blue Cross,

National Association of Insurance Commissioners,

National Association of Medicaid Fraud Control Units,

National Health Care Anti-Fraud Association,

National Insurance Crime Bureau,

New York Office of Medicaid Inspector General,

Travelers,

Tufts Health Plan,

UnitedHealth Group,

U.S. Department of Health and Human Services,

U.S. Department of Justice, and

WellPoint Inc.

“Bringing additional healthcare industry leaders and experts into this work will allow us to act more quickly and effectively in identifying and stopping fraud schemes, seeking justice for victims, and safeguarding our healthcare system,” says Attorney General Eric Holder.

Go back to current issue of eConsult