Health Reform Tools Combat Medicare Fraud

Health Reform Tools Combat Medicare Fraud

On April 4th the seventh summit was held in Chicago by the Department of Justice and Health & Human Services (HHS). During the summit, Attorney General Holder stated that “Through HEAT (Health Care Fraud Prevention and Enforcement Action Team) we have achieved unprecedented, record‐breaking successes in combating health care fraud and as a result of the Affordable Care Act, we have additional critical resources, tools, and authorities to continue this great success.”
The Centers for Medicare & Medicaid Services (CMS) is using state‐of‐the‐art technology review claims before they are paid to track fraud trends and flag suspect activity. New power to fight fraud, granted in the health reform law, will also help achieve the 2012 goal of cutting the rate of improper payment claims in the traditional Medicare program by half. Secretary Sebelius said, “Thanks to health reform and our administration’s work, we have new tools and resources to catch criminals and stop Medicare fraud before it happens.” The new tools provided by the Affordable Care Act help strengthen the Obama administration’s efforts to fight health care fraud. As a result of Affordable Care Act provisions:

• Criminals face tougher sentences for health care fraud, 20‐50 percent longer for crimes that involve more than $1 million in losses;
• Contractors that police Medicare for waste, fraud, and abuse will expand their work to Medicaid, Medicare Advantage, and Medicare Part D programs;
• Government entities, including states, the Centers for Medicare & Medicaid Services (CMS), and law enforcement partners at the Office of the Inspector General (OIG) and DOJ, have greater abilities to work together and share information so that CMS can prevent money from going to bad actors by using its authority to suspend payments to providers and suppliers engaged in suspected fraudulent activity.

Since the creation of HEAT in 2009, the Medicare Fraud Strike Force operations have expanded to nine locations throughout the United States. Overall, in the fiscal year 2011, strike force operations charged a total of more than 320 defendants for allegedly billing more than $1 billion in false claims.
During the summit, the Obama administration announced more progress from its anti‐fraud efforts, beyond the nearly $4.1 billion recovered last year. 234 providers were removed from the Medicare program because they were deceased, debarred or excluded by other federal agencies, or were found to be in false storefronts or otherwise invalid business locations; HHS revoked 4,850 Medicaid providers and suppliers and deactivated 56,733 Medicare providers and suppliers as it took steps to close vulnerabilities in Medicare; saved $208 million through pre‐payment edits that stop implausible claims before they are paid; and more.
For the press release from the US Department of Health & Human Services, please visit http://www.ahrq.gov/news/press/pr2012/highvaluepr.htm.