Public-Private Partnership New Tool in Fight Against Health Care Fraud

On July 26, 2012, Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder announced that the federal government and several leading private and state organizations have teamed up to detect and prevent payment of fraudulent health care billings. In the short term, the voluntary partnership will be a medium through which information and best practices will be shared. The longer term goal is to be able to perform sophisticated analysis that will detect and predict fraud schemes. Members are hoping that the partnership will aid in revealing and stopping scams that involve public and private payers. One short term goal of the partnership is to be able to detect when two insurers are being charged for care provided to one patient in different cities on the same day.

Secretary Sebelius said, “This partnership puts criminals on notice that we will find them and stop them before they steal health care dollars.” She also credited the Affordable Care Act with providing additional necessary anti-fraud tools.

The operational structure of the partnership is still being worked out, and the first meeting between the Executive Board, the Data Analysis and Review Committee, and the Information Sharing Committee is planned for September. There are a number of organizations and agencies that have been quick to join this partnership.

The Affordable Care Act has already provided additional tools to combat fraud. The Centers for Medicare and Medicaid Services (CMS) is already using new technology to review claims before they are paid in order to track fraud and flag suspect activity. The Affordable Care Act also increases sentencing guidelines for health care fraud by 20-50% for crimes involving more than $1 million in losses and makes it easier for the government to recover lost funds. Between 2009 and 2011, convictions under the Health care Fraud and Abuse Program increased by more than 27%.

The Affordable Care Act expressly authorizes CMS to suspend payments to providers or suppliers while an investigation for fraud is ongoing. This is a big change to the prior practice of paying all claims, then trying to recoup money once fraud is detected.

For more information regarding this and related issues, please contact Carey Kalmowitz, Esq., or Adrienne Dresevic, Esq., at (248) 996-8510 or visit the HLP website.