HHS announces unprecedented public-private partnership to fight fraud
WASHINGTON - In late July the U.S. Department of Health and Human Services announced an unprecedented partnership between the federal government, state officials, private health insurer organizations and a number of other anti-fraud groups focused on preventing healthcare fraud.
The effort, which is still in its formative stages, furthers the Administration's emphasis on snuffing out healthcare fraud in what it promises will be a coordinated effort that will share information and best practices. The focus will be on markets that are known hot spots for healthcare fraud in order to detect and stop scams that cut across both public and private payers.
"This new partnership will allow those on the front lines of industry anti-fraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders," said Attorney General Eric Holder at a July 26 press announcement of the new partnership. "It will help law enforcement officials utilize cutting-edge technologies to more effectively identify and prevent suspicious activities, and to safeguard precious taxpayer resources."
According to industry observers, the partnership between public and private stakeholders, including many of the country's largest private health insurers, the Blue Cross Blue Shield Association and America's Health Insurance Plans (AHIP), was both a long time coming and a necessary measure to continue the fight against healthcare fraud.
"This is not only important for the insurance industry, but it is also important for government, for consumers, for medical providers, for everybody who is involved in healthcare," said Dennis Jay, executive director of the Washington-based Coalition Against Insurance Fraud. "Our advocacy of such a group goes back many years where we saw the government combatting insurance fraud, the private sector combatting insurance fraud and they both were acting like they were dealing with their own set of crooks when they were dealing with many of the same characters. We felt that if they teamed up, they might be more successful in detecting the scams and detecting them earlier."
The effort is especially important now, Jay noted, because those looking to defraud healthcare payers are more organized and sophisticated than they have ever been.
At the Blue Cross and Blue Shield Association, the cooperative effort should make it even more effective in its own efforts, which last year resulted in the recovery of more than $295 million dollars and the conviction of 197 people.
Lisa Joldersma, managing director for policy and regulation at BCBSA said creating a national effort to combat fraud is an effective way to "roll up" the fraud fighting capabilities of its member companies, other private insurers as well as what the federal government has learned from its recent efforts focusing on fraud hotspots across the country.
"One area being worked on by the partnership right now would be for all of the partners to identify what are the common characteristics of a fraud scheme," said Joldersma. "And that could be what are the codes, billing patterns and those sorts of things. If you share those, them everyone can go and check."
The cooperation between fraud organizations and public and private payers may require the additional participation of service providers to the industry, noted Bill Lucia, president and CEO of Irving, Texas-based HMS, which works with CMS and 35 states to improve payment integrity and root out fraud, waste and abuse.
One area where Lucia thinks the partnership members will need help in is finding a common format for the data the different payers are using in order to share their information and effectively determine patterns of fraud from one payer to the next.
"Without this type of collaboration we won't aggressively solve the problem of fraud, waste and abuse in the healthcare industry," Lucia said. "But it will need private industry support and knowledgeable people to work on it, as well as some regulatory changes to allow this data to be shared to make it work."