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On July 26, 2012, the U.S. Department of Health and Human
Services (HHS) and the U.S. Attorney General's Office announced
that the federal government is creating a partnership with private
payers and other state and private entities to attack health care
fraud. Twenty-one organizations and agencies, including HHS, CMS,
DOJ, FBI, Blue Cross and Blue Shield Association, Humana, and
Wellpoint, have joined the partnership.1
Partnership members have agreed to the unprecedented step of
proactive, pre-case information-sharing about specific schemes,
billing codes, and "hot" fraud locations. According to
the Coalition Against Insurance Fraud, one of the founding
partnership members, participants "will share case leads,
evidence, data, and other vital information" to try to prevent
fraud and to facilitate False Claims Act lawsuits and criminal
prosecutions.2 (The partners also have committed to
sharing only "scrubbed" data, to protect patient
privacy.) Specific future goals of the partnership include
preventing providers from billing two different insurers for the
same patient care and predicting health care fraud schemes. The
partnership's working groups are already meeting to structure a
work plan, and its board, data analysis committee, and
information-sharing committee will meet in September 2012.
The partnership arose from the Coalition Against Insurance
Fraud's offer to HHS to coordinate a health care fraud summit
in 2010,3 and is further evidence of the Obama
administration's full-throttle effort to reduce fraud and abuse
in health care, and to recover public and private losses in the
industry. The partnership complements, and in many ways is a
natural extension of, the ever-escalating anti-fraud efforts,
including increased criminal prosecutions, civil lawsuits, the
recently implemented Stark Self-Referral Disclosure Protocol, and
the Patient Protection and Affordable Care Act's provision for
longer criminal sentences for certain categories of health care
fraud.
Prosecuting fraud and abuse has been a state and federal
government priority for several years, and diligent health care
providers and suppliers have implemented their own anti-fraud
programs and compliance plans. With growing public/private
resources and fewer barriers to information-sharing, providers and
suppliers should anticipate more scrutiny of all claims —
whether they are sent to public or private payers. The
government's best options for pursuing non-governmental health
care fraud include criminal prosecutions under a variety of
theories. While the government could always pursue private actors,
it has sometimes been stymied by a lack of access to data,
documents, and witnesses. By working with private entities, the
executive branch likely hopes to expand its fraud-fighting toolkit
even more. For their part, the private partners' voluntary
participation is likely seen as a commitment to joining the
government's battle. This partnership, especially when viewed
as one more arrow in the government's quiver, suggests that all
providers and suppliers — irrespective of their payer mix
— will need to focus on, and obtain management buy-in
for, careful monitoring to assure compliance with fraud and abuse
laws. In sum, with more entities joining the fight against fraud
and abuse, it may be getting harder to stay beneath the
government's radar.
Footnotes
1. The following organizations and government agencies
are members of the partnership: America's Health Insurance
Plans, Amerigroup Corporation, Blue Cross and Blue Shield
Association, Blue Cross and Blue Shield of Louisiana, Centers for
Medicare & Medicaid Services, Coalition Against Insurance
Fraud, Federal Bureau of Investigations, Health and Human Services
Office of Inspector General, Humana Inc., Independence Blue Cross,
National Association of Insurance Commissioners, National
Association of Medicaid Fraud Control Units, National Health Care
Anti-Fraud Association, National Insurance Crime Bureau, New York
Office of Medicaid Inspector General, Travelers, Tufts Health Plan,
UnitedHealth Group, U.S. Department of Health and Human Services,
U.S. Department of Justice, WellPoint, Inc. "Obama
Administration Announces Ground-Breaking Public-Private Partnership
to Prevent Health Care Fraud," Department of Health and Human
Services, available at http://www.hhs.gov/news/press/2012pres/07/20120726a.html
(July 26, 12).
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