Health Care Fraud in the News Again

Last week, the President hosted a Medicare Fraud summit to evaluate new ways to combat Medicare Fraud. During the summit, one of the attendees noted that he government "cannot prosecute its way out of the Health Care Fraud problem."  On the heels of the summit, the Administration announced its FY 2011 budget.  The budge includes $1.7 billion for Medicare Fraud enforcement.  This money will be used for a number of efforts:  it will more than double the Health Care Fraud and Abuse Control discretionary funding, it will expand the DOJ/HHS joint strike force efforts, it will provide for better data sharing, and increase oversight and prevention.

The data sharing plan is discussed more fully here.  Essentially, Medicare is continuing its efforts to consolidate all of its claims data into one place.  Then they can use datamining techniques to look for patterns in the data.  In the statement, Secretary Sebelius mentions the use of benchmarking to identify questionable practices.  I have mentioned this plan on this blog before - essentially, they will use the data to identify providers/areas with questionable practices and then focus on these providers.  This allows them to "target" their investigations.  

Of course, smart criminals will account for this and strive to keep their billing within certain parameters or go wild, get as much as they can as fast as they can and get out before the investigators arrive.  (I don't mean to be negative, but my my years doing primarily criminal defense led me to conclude that "locks only keep honest people out.")  Another area they might focus on more is in the area of enrollment and controlling who gets into the system.  OIG mentioned this twice in testimony to Congress this year.  Although as with every other anti-fraud system, criminals can manipulate this one as well.  (Although as you make it harder and harder on the criminals, Medicare stops being "easy money.")

It is not clear how effective this will be, as one of the main topics of the Fraud Summit was the amount of fraud that is still being perpetrated on the Medicare/Medicaid system, even after the government's recent efforts to crack down on fraud. One speaker commented that the recent successes is simply the "low hanging fruit".  He was implying that there is much more fraud to be identified and stopped. Another issue that raises questions about the effectiveness of the programs is the statistic mentioned in the USA Today article - for all the additional fraud enforcement efforts, prosecutions are only up 2%.   

Regardless of whey prosecutions are only up 2% over last year, the real point from all of these articles is that HHS and the DOJ are continuing to ramp up their MEdicare fraud enforcement efforts.  This should serve as a warning to everyone in the home health and hospice industries.  The HHS/DOJ strikeforces and HHS in general are already focused on you.  They are now adding to the resources at their disposal to investigate and prosecute Medicare fraud.  

This means you should be focusing even more on your compliance efforts.  Given the ever increasing focus on reviewing claims data, a good place to start is auditing and monitoring your claims.  Are there any reasons your claims might stand out?  Do you have a large number of outliers?  Does your documentation support your billing practices?  These are the kinds of questions you should be asking yourself, especially now that you know what they will be looking at.  If you have not looked at your compliance plan in a while (or longer) now is an excellent time to start.  Fraud and Abuse enforcement is only going to become more aggressive in the future.  The time to prepare is now.

Comments

[Patty Nay]

There is fraud all over the place. Every industry suffers from it. Seems as though there just has to be a reason for all the cutbacks that are taking place. Why is it the health care industry? Medicare for instance. What is that all about?

www.karowhomecare.com

[Robert Markette]

I think healthcare is an easy target (especially home health and hospice where the national trade associations lack a real war chest). This is furthered by the recent spate of high profile fraud problems in places like Miami and LA. Yes, there is fraud in Medicare, but to paint the entire home health industry as the problem is unfair and inaccurate. (But it does make a convenient excuse to reduce reimbursement, which is rather convenient for CMS.)

Bob