US Department of Health and Human Services (HHS) Secretary Kathleen Sebelius and US Attorney General Thomas J. Perrelli yesterday released a new report showing that the government’s health care fraud prevention and enforcement efforts recovered more than $4 billion in taxpayer dollars in fiscal year 2010—the highest amount ever recovered from people who attempted to defraud seniors and taxpayers. In addition, HHS announced new rules authorized by the Affordable Care Act that will help the department work proactively to prevent and fight waste and abuse in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).
The Affordable Care Act provides federal agencies additional tools and resources to help federal agencies fight fraud, including an additional $350 million for the Health Care Fraud and Abuse Control Program (HCFAC), a joint program between HHS and the Department of Justice to coordinate federal, state, and local law enforcement activities to fight health care fraud and abuse. The HCFAC was chiefly responsible for the $4 billion dollar recovery announced yesterday.
New rules under the Affordable Care Act now will authorize the use of enhanced screenings and enrollment requirements, increased data sharing across government, expanded overpayment recovery efforts, and greater oversight of private insurance abuses. These new rules will help the HHS do less “paying-and-chasing” fraudulent health care claims and do more proactive fraud prevention by stopping criminals from getting into the system in the first place. Specifically, the new rules:
- Create a rigorous screening process for providers and suppliers enrolling in Medicare, Medicaid, and CHIP to keep fraudulent providers out of those programs. Types of providers and suppliers that have been identified in the past as posing a high risk of fraud, for example durable medical equipment suppliers, will be subject to a more thorough screening process.
- Require a new enrollment process for Medicaid and CHIP providers. Now states will have to screen providers who order and refer to Medicaid beneficiaries to determine if they have a history of defrauding the government. Providers that have been kicked out of Medicare or another State’s Medicaid or CHIP will be barred from Medicaid and CHIP programs.
- Temporarily stop enrollment of new providers and suppliers. Medicare and state agencies will be on the lookout for trends that may indicate health care fraud—including advanced predictive modeling software, such as that used to detect credit card fraud. If a trend is identified in a category of providers or geographic area, the program can temporarily stop enrollment as long as that will not impact access to care for patients.
- Temporarily stops payments to providers and suppliers in cases of suspected fraud. Under the news rules, if there has been a credible fraud allegation, payments can be suspended while an action or investigation is underway.
Source: US Health and Human Services