Anti-fraud efforts focus of federal summit

Washington -- Two federal departments that have combined forces over the past year to reclaim billions of dollars lost to health care fraud and to secure hundreds of criminal convictions hosted a national summit on Jan. 28 to discuss how they can continue to improve operations.

Efforts to combat fraud in the Medicare and Medicaid programs also received a boost when President Obama requested $1.7 billion for those activities in his fiscal 2011 budget, an increase of $250 million over the 2010 enacted level. The White House estimates these investments would generate $9.9 billion in savings from increased fraud recoveries and prevention.

Highlighting the fraud summit were the results generated by an anti-fraud unit that was formed in May 2009. The Health Care Fraud Prevention and Enforcement Action Team is a joint effort by the Dept. of Health and Human Services and the Dept. of Justice. It has secured more than 50 guilty pleas and identified more than a quarter of a billion dollars in fraudulent billings over the past eight months.

U.S. Attorney General Eric Holder said the departments will continue to strengthen HEAT by forming new Medicare fraud strike teams. There are currently offices in Baton Rouge, La.; Brooklyn, N.Y.; Detroit; Houston; Los Angeles; Miami and Tampa, Fla.

"Our agencies will continue to work with Congress to identify and pursue the legislative and regulatory reforms necessary to prevent, deter and prosecute health care fraud," Holder said. "These reforms range from removing barriers that impede information-sharing to increasing sanctions and penalties."

The departments noted how Medicare claims data used to be scattered among several databases belonging to different contractors, but said they are now combining all data in a single, searchable location. They also said new tools and methods have helped spot fraud trends, whether by geographic area or by type of billings.

"For example, we were recently able to see that Miami-Dade County, which is home to 2% of Medicare home health patients, has 90% of home health patients receiving more than $100,000 in care each year," said HHS Secretary Kathleen Sebelius. "When you see numbers like that, you don't need a PhD in statistics to know something is going on."

Advice from physicians

The American Medical Association participated in the summit and offered recommendations on immediate actions the Obama administration could take to curb fraud further.

"Health care fraud is a significant concern to the medical community, and it takes resources away from patient care as we work to maximize the value of every health care dollar," said AMA Chair-elect Ardis Dee Hoven, MD. "Both patients and physicians have been victims of medical identity theft and other fraudulent schemes, so it's important that the physicians, insurers, and the regulatory and enforcement communities work together to tailor ways to combat fraud."

One area that HHS can address relates to the growing problem of physician ID theft, Dr. Hoven said. Doctors have no ability to control access to their National Provider Identifier, and the government has acknowledged its misuse by criminals. The department can take immediate steps to limit access to NPIs and create a national office to help physician victims of identity theft reclaim their good standing, she said.

"Physicians are doing their best to provide high-quality patient care in a fragmented health system," Dr. Hoven said. "HHS should target areas where fraud truly occurs to be most effective, instead of adding onerous burdens on physicians."

Targeting equipment fraud

Prosecuting fraud is one way to help curtail it, but the most effective method is to stop it from happening in the first place, HHS and Justice Dept. officials said.

One example HHS cited was the work it has undertaken to stop fraudulent claims for durable medical equipment. These activities used to be very appealing to criminals because it was easy to set up a fake storefront, but more random site visits and mandatory accreditation has put a damper on that, Sebelius said.

"All you had to do was rent a room, put some equipment on the shelves, get a phone line and you were set," she said. "But in the last year we've made it a lot harder for crooks to run this scam."

The American Assn. for Homecare, which represents durable medical equipment suppliers, was not asked to participate in the January event. "The national 'summit' on health care fraud, convened by HHS and DOJ, is going forward without the benefits of the perspective and insight of the home medical equipment sector, and we object to being left out of the discussions," said Tyler J. Wilson, the association's president.

The organization proposed a 13-point anti-fraud plan to Congress last year, calling for real-time audits and screens to catch fraudulent claims. But the group opposes a Medicare competitive bidding program for equipment, saying the process, in place in selected communities, decreases patient access and forces legitimate suppliers out of the system.