New Tools to Fight Fraud, Strengthen Federal and Private Health Programs, and Protect Consumer and Taxpayer Dollars
Recent Initiatives Help the Government Fight Fraud, Strengthen Health Insurance Programs, and Protect Consumer and Taxpayer Dollars
The Obama Administration has made important strides in reducing fraud, waste, and abuse across the government. Over the last two years, the Centers for Medicare & Medicaid Services (CMS) has implemented powerful new anti-fraud tools and designed and implemented large-scale, innovative improvements to our Medicare program integrity strategy to shift beyond a “pay and chase” approach to preventing fraud before it happens. CMS is also collaborating more with the private sector, law enforcement, and our state partners to harness best practices in our fight against health care fraud.
These efforts are paying off. In FY 2012, the government recovered a historic $4.2 billion and has returned a record-breaking $14.9 billion dollars to taxpayers between 2009 and 2012, up from $6.7 billion dollars over the prior four years.
The Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint effort between the Department of Health and Human Services (HHS) and Department of Justice (DOJ) to fight health care fraud, has played a critical role in these efforts. A key component of HEAT is the Medicare Strike Force – interagency teams of analysts, investigators, and prosecutors who can target emerging or migrating fraud schemes, including fraud by criminals masquerading as healthcare providers or suppliers.
In October 2012, Medicare Strike Force operations in seven cities led to charges against 91 individuals – including doctors, nurses and other licensed medical professionals – for their alleged participation in Medicare fraud schemes involving approximately $432 million in false billing. That total includes more than $230 million in home health care fraud; more than $100 million in community mental health care fraud and more than $49 million in ambulance transportation fraud. In coordination with the criminal charges, HHS also suspended or took other administrative action against 30 health care providers following a data-driven analysis and credible allegations of fraud. Under the Affordable Care Act, HHS is able to suspend payments until an investigation is complete. In May 2012, Medicare Strike Force teams charged 107 individuals, including doctors, nurses and other licensed medical professionals, in seven cities for their alleged participation in Medicare fraud schemes involving more than $452 million in false billing.
In 2011, HEAT coordinated the largest-ever federal health care fraud takedown involving $530 million in fraudulent billing. In one action, Strike Force teams charged 115 defendants in nine cities, including doctors, nurses, health care company owners and executives, for their alleged participation in Medicare fraud schemes involving more than $240 million in false billing. In another coordinated takedown, Strike Force prosecution teams charged 91 defendants in eight cities for their alleged participation in a Medicare fraud scheme involving more than $290 million in false billings.
Other steps the Administration has taken to fight fraud include:
Tough New Rules and Sentences for Criminals: An unprecedented collaboration between HHS and the DOJ on the joint HEAT Strike Force has charged more than 1,400 defendants who collectively have falsely billed the Medicare program more than $4.8 billion since 2007. In 2012, the Department of Justice opened 1,311 new criminal health care fraud investigations involving 2,148 defendants. And thanks to the Affordable Care Act, criminals convicted of fraud now face tougher sentences and more jail time. Criminals will receive 20 to 50 percent longer sentences for crimes that involve more than $1 million in losses. The law also establishes penalties for obstructing a fraud investigation or audit and makes it easier for the government to recapture any funds acquired through fraudulent practices.
Healthcare Fraud Prevention Partnership: The Obama Administration’s fight against healthcare fraud now includes the ground-breaking Healthcare Fraud Prevention Partnership, a forum for the federal government and private and state organizations, including insurers, to prevent healthcare fraud on a national scale. To detect and prevent payment of fraudulent billings, the Partnership seeks to exchange information and best practices across the public and private sectors. The Partnership will also perform sophisticated analytics on industry-wide data that will detect and predict fraud schemes that were previously undetectable in a fragmented healthcare system.
Use of State-of-the-Art Fraud Detection Technology: In June 2011, CMS began screening all fee-for-service Medicare claims through the new Fraud Prevention System. Similar to the technology used by credit card companies, the Fraud Prevention System applies predictive analytic technology to claims prior to payment to identify aberrant and suspicious billing patterns. Leveraging leads from this system, CMS and its contractors perform reviews, in an effort to stop claims before payment, and trigger administrative actions and law enforcement referrals. Early results from the Fraud Prevention System show significant promise. In its first year of implementation, the Fraud Prevention System:
- Generated leads for 538 new fraud investigations
- Provided new information for 511 existing investigations
- Triggered 617 provider interviews and 1,642 beneficiary interviews
Senior Medicare Patrols: As a part of the new resources dedicated to fighting fraud, the Obama Administration has significantly expanded funding for Senior Medicare Patrols – groups of senior citizen volunteers who educate and empower their peers to identify, prevent and report health care fraud. In 2012, the Secretary awarded 54 states and territories with funding to support the Senior Medicare Patrol programs Last year, these programs taught more than 2 million beneficiaries how to look for Medicare fraud. Local Senior Medicare Patrol offices provide assistance when such issues are identified, so that mistakes are corrected and suspected fraud referred to the appropriate authorities. Since 1997, more than 1.5 million seniors and their caregivers have contacted the Senior Medicare Patrol to ask questions or report potential fraud.
Enhanced Provider Screening and Enrollment Requirements: CMS has implemented powerful anti-fraud tools from the Affordable Care Act. Providers and suppliers wishing to participate in Medicare, Medicaid, and the Children’s Health Insurance Program who may pose a higher risk of fraud or abuse are now required to undergo a higher level of scrutiny.
CMS has embarked on an ambitious project to revalidate the enrollments of all existing 1.5 million Medicare providers and suppliers by 2015. This scrutiny includes licensure checks and site visits to confirm legitimacy and location. High and moderate risk providers and suppliers are subject to unscheduled site visits, and high risk providers and suppliers soon will be subject to fingerprint-based criminal background checks.
Since March 2011, CMS enrolled or revalidated enrollment information for nearly 410,000 Medicare providers and suppliers under the enhanced screening requirements of the Affordable Care Act. As a result of revalidation and other proactive initiatives, CMS has deactivated 159,449 enrollments and revoked 14,663 enrollments. These efforts will ensure that only qualified and legitimate providers and suppliers can provide health care items and services to Medicare beneficiaries.
The Affordable Care Act also limits the ability of fraudulent providers and suppliers to move from state to state or between Medicare and Medicaid by requiring all states to terminate anyone whose billing privileges have been revoked by Medicare or who has been terminated by another state Medicaid program for cause.
Greater Oversight of Private Insurance Abuses: The new law also provides enhanced tools and authorities to address abuses of multiple employer welfare arrangements and protect employers and employees from insurance scams. This, plus the new rules to ensure accountability in the insurance industry, will protect consumers and increase the affordability of health care.
Posted on: March 15, 2011
Last updated: February 11, 2013