Campaign against health care fraud questioned

A lower conviction rate has put the spotlight on federal officials, who say prevention is hard to measure.

By Alicia Gallegos — Posted Jan. 18, 2011

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Federal programs aimed at battling health care fraud are under scrutiny after a recent analysis showed a decrease in criminal fraud convictions.

Sen. Charles Grassley (R, Iowa) criticized Attorney General Eric Holder and the Dept. of Justice in December 2010 based on his office's review of Justice Dept. and Centers for Medicare & Medicaid Services data. The analysis found that 583 of 803 criminal defendants charged in 2009 were convicted or pleaded guilty -- a 72% conviction rate compared with past rates that topped 90%, he said.

"Statistically speaking, the data ... [show] that despite increased cases and defendants, fewer bad guys are going to jail for ripping off Medicare and Medicaid," Grassley said in a statement. "I want to know why the Justice Dept. is having a tougher time putting people behind bars when we're giving them millions more to do the job."

But government officials and others argue that counting culprits may not be the best measure of anti-fraud efforts, since much of the renewed focus has shifted to the strategy of prevention, which is more difficult to quantify.

"You can't measure the number of fraud systems or effort by criminal cases," said Louis Saccoccio, executive director of the National Health Care Anti-Fraud Assn., a group of private insurers and public agencies. "It's not a good measure if the federal government is doing a good job fighting health care fraud."

The Justice Dept. did not respond to Grassley's assertions or data analysis. But the agency said in a statement that since the creation of the Health Care Fraud Prevention and Enforcement Action Team in 2009, it has made significant strides in fighting fraud.

Those achievements, according to the department, include charging more than 500 defendants, returning about $441 million in Medicaid money to the Treasury Dept. and resolving health fraud cases in 2010 that recovered more than $2.5 billion, the highest sum ever obtained in a single year.

Saccoccio called Grassley's conviction figures "misleading," pointing to the government's improved concentration on fraud risk management. Those efforts include closer screening of health professionals and deeper data analysis of claims.

Education as anti-fraud weapon

Education is another prime tool of anti-fraud agencies such as the Senior Medicare Patrol, a program of the Dept. of Health and Human Services Administration on Aging. The project, which has expanded to all 50 states, Guam and Puerto Rico, works to help seniors identify suspicious bill items, said Barbara Dieker, director of the Office of Elder Rights for the AOA.

Dieker said that several years ago, the project wanted to demonstrate its results more clearly, so it established performance measures and a centralized system to capture the data. The reports, now online, show the number of program volunteers, inquiries, Medicare outreach efforts and Medicare money saved (link).

"It is important that all government-funded programs be able to show the results of the taxpayers' investment," Dieker said. "Today, government programs must be able to document their value -- both that which is quantifiable and also the stories that provide a qualitative perspective -- for those who must make the hard choices about how best to allocate precious federal dollars."

Peter Budetti, MD, director of the CMS Center for Program Integrity, said CMS and other federal agencies are working toward a similar system of performance assessment to better reflect the success of their programs.

"It's a high priority," he said. "We genuinely believe what we're doing will be effective, and we understand we have to be held accountable."

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