Fighting Health Care Fraud

The Obama Administration has made fighting health care fraud one of our top priorities.  In Medicare and Medicaid, these efforts are already paying off.  This year, we announced a record recovery of $4.1 billion in taxpayer dollars. Four years ago, that number was only a little more than $1 billion.

These efforts reflect a broad range of steps we have taken to improve our ability to detect and go after fraud.  For instance:

•             Under the Affordable Care Act, we have new authorities to fight fraud.  This includes additional scrutiny for higher risk categories of providers and suppliers before they’re able to bill Medicare, Medicaid and the Children’s Health Insurance Program (CHIP); and new authority to suspend payments during the investigation of fraud.

For example, this week we suspended payments to home health providers in Texas related to a recent fraud bust.

•             We’ve instituted tougher new rules and sentences for criminals.  From 2008 to 2011, there has been a 75 percent increase in individuals charged with criminal health care fraud.

•             We are implementing a ground-breaking Healthcare Fraud Prevention Partnership, where the federal government and private and state organizations, including insurers, work together to prevent health care fraud.

•             And we have implemented a new Fraud Prevention System that uses predictive modeling technology, similar to the technology that credit card companies use to flag suspicious activity, to review medical claims before they are paid.

Today, we released a report on the first year results of the Fraud Prevention System (http://www.stopmedicarefraud.gov/fraud-rtc12142012.pdf). Since the technology was first rolled out in 2011, all Part A and B Medicare claims – over one billion – have run through the system.   In the first year in operation, the system initiated 536 new investigations and helped stop, prevent, or identify an estimated $115 million in fraudulent payments.

We are working to continue improving our system and refine the way we track our results.  Our law enforcement partners have made important suggestions on how to improve our metrics for reporting these savings, and we are working to implement their recommendations.  They agree – this is an important system that will strengthen our efforts to fight fraud, waste and abuse.

Fighting fraud continues to be a top priority for the Administration, and we will continue implementing innovative new approaches that will protect taxpayer dollars.  For more information on our efforts to fight fraud, please visit: http://www.healthcare.gov/news/factsheets/2011/03/fraud03152011a.html.

Command Center Speeds Up Anti-Fraud Efforts

By Dr. Peter Budetti, CMS Deputy Administrator and Director of the Center for Program Integrity

Today, I had the privilege of joining HHS Secretary Kathleen Sebelius and CMS Acting Administrator Marilyn Tavenner to open the new CMS Program Integrity Command Center that is speeding up the process of identifying fraud, and stopping criminals from defrauding Medicare and Medicaid.

The new Command Center is bringing together Medicare and Medicaid officials, as well as law enforcement partners from the HHS Office of the Inspector General, the Federal Bureau of Investigation, and CMS’s anti-fraud investigators. The Command Center will gather experts from all different areas – clinicians, data analysts, fraud investigators, and policy experts – into the same room to build and improve our sophisticated new predictive analytics that spot fraud, and to then move quickly on a lead, once potential fraud is identified. The technology also allows us to connect with field offices to track down leads in real time.

The result is that investigations that used to take days and weeks can now be done in a matter of hours. And this new technology can help detect and prevent potential problems and payments. That can mean millions of taxpayer dollars staying out of the hands of fraudsters.

This is one more part of the Obama Administration’s effort to fight fraud and waste in our health care system. The health reform law gives law enforcement more tools to go after fraudsters, and establishes tougher sentences once we catch those criminals. We’re already seeing results – four years ago, the government recovered just over $1 billion in fraudulent payments; this year, it’s over $4 billion, a record number. We’ve had the largest health care fraud busts in history in 2012.

Below, view a preview of this exciting facility that’s helping us protect the Medicare and Medicaid programs:

Industry Day – By Peter Budetti, CMS Deputy Administrator and Director for the Center for Program Integrity

We at the Centers for Medicare & Medicaid Services (CMS) continue to ramp up our efforts to fight health care fraud as we welcome more than 330 people representing nearly 200 vendors to Industry Day on October 15 from 9:00 am to 5:00 pm at our Central Office complex in Baltimore, Maryland.  Our Center for Program Integrity (CPI) is hosting the event, which is designed to identify state-of-the-art services, methods and products that could help us to prevent and detect fraud, and to reduce waste, abuse and other improper payments under the Medicare and Medicaid programs.

Industry Day is the first of a two-phase market research initiative where we’ll be sharing our strategic goals, priorities and objectives to prevent and detect fraud.  We’ll also provide an overview of our capabilities and initiatives related to Medicare and Medicaid program integrity, including the process of developing IT solutions within the context of the CMS Technical Reference Architecture and Integrated IT Investment & System Life Cycle Framework.  Based on the information we present, interested vendors can determine if the services, methods and products they offer can support our fraud prevention efforts.

The second and final phase of our market research initiative will start in late November when we plan to send an online invitation (through the FedBizOpps website) asking interested vendors to submit capability statements for the following four areas:  provider screening, predictive modeling, case management and data integration.  We’ll review and select capability statements in each area and schedule meetings with some vendors starting in January 2011.

We look forward to seeing you tomorrow!