In new effort to tackle health care fraud, government and insurers to scrutinize claims data

http://seanmarley.livejournal.com/4258.html

WASHINGTON — The Obama administration is upping the ante in the 

fight against health care fraud, joining forces with private insurers and 

state investigators on a scale not previously seen in an attempt to stanch 

tens of billions of dollars in losses.

Health and Human Services Secretary Kathleen Sebelius said in a 

statement Thursday that the new public-private partnership “puts 

criminals on notice that we will find them and stop them,” while 

Attorney General Eric Holder called it “a critical step forward” against 

fraud, an endemic problem plaguing programs like Medicare and 

Medicare as well as private insurance companies.

Details of the collaboration remain to be worked out, but the 

possibilities include sharing information on new fraud schemes as they 

pop up, using claims data to catch scams such as payments billed to 

different insurers on the same day for care purportedly delivered to the 

same patient in different cities, and using computer analysis to spot 

emerging patterns of fraud.

The agreement is also unusual because it brings the Obama 

administration and longtime foes in the insurance industry together to 

tackle a common problem. While carrying out the requirements of 

President Barack Obama’s health care overhaul law, insurers are also 

lobbying to roll back some of its provisions, such as new taxes on the 

industry and cuts to private plans offered through Medicare. Obama 

continues to rail against industry “abuses.”

Fraud is estimated to cost Medicare about $60 billion a year, and the 

Obama administration has beefed up the government’s efforts to stop it, 

bringing in record settlements with drug companies for marketing 

violations as well as using new powers in the health care law to pursue 

low-level fraudsters with greater zeal.

Yet, although Medicare is becoming a harder target, it’s too early to say 

if the tide has turned.

Some antifraud efforts launched with great fanfare have yet to deliver 

convincing results. For example, a $77-million computer system 

unveiled last summer to stop Medicare fraud before it happens had 

prevented just one suspicious payment by Christmas.

Likewise, the new public-private collaboration could face problems. 

Privacy advocates may object to extensive scrutiny of claims data, and 

doctors have traditionally pushed back against routine computerized 

monitoring of their practice patterns.

A formal announcement of the campaign was scheduled Thursday 

afternoon at the White House, with top insurance industry officials 

participating. Supporting the partnership are America’s Health Insurance 

Plans, the leading industry lobbying group, the Blue Cross and Blue 

Shield Association, and major companies including UnitedHealth Group 

and WellPoint, Inc. Formal working meetings are scheduled for 

September.

The analysis of data from Medicare, Medicaid and private health plans 

will look for suspicious patterns and other evidence that might indicate 

fraud, White House officials said. A “trusted third party” would comb 

through the data and turn questionable billing over to insurers or federal 

investigators.

Officials said those who submit fraudulent claims often do so for both 

government programs and private insurance plans. Separately, such 

claims might not raise suspicions, but taken together they could raise a 

red flag, such as when a doctor bills for more than 24 hours in a day.

Law enforcement organizations taking part in the collaboration include 

the FBI, the Health and Human Services Inspector General’s Office, the 

Justice Department, and state and private insurance fraud control units.

Copyright 2012 The Associated Press. All rights reserved. This material 

may not be published, broadcast, rewritten or redistributed.