Recent anti-fraud success, health reform law provisions show government, insurers getting serious about health care fraud

Reports released within the past month by both government health authorities and health insurers highlight recent successes in combating health care fraud and saving or recovering substantial amounts of money. A Blue Cross and Blue Shield Association study reporting anti-fraud efforts in the past year found that investigations by the Association’s member companies yielded over $500 million, a nearly 50 percent increase compared with 2008. For it’s part, the Department of Health and Human Services announced over $2.5 billion recovered through last year’s health care fraud efforts, in addition to $441 million recovered from Medicaid through similar anti-fraud programs. Both of these were significant increases from prior year results, and future prospects appear even brighter, due to new provisions and additional funding related to fraud prevention included with the Patient Protection and Affordable Care Act (the recently enacted health reform legislation). Both government and industry efforts to combat fraud are taking a multi-pronged approach, including more education and training to health care staff and individual citizens to make them more aware of scams or other potentially fraudulent activities. There also seems to be a significant emphasis on applying analytical tools and anti-fraud technologies, and to use those tools earlier in the health care claims process, to catch fraud before payment is made (prevention works better than after-the-fact recovery). Overall, the attention to detecting and preventing fraud reflects a widespread industry shift in focus, away from a single-minded prioritization of efficient claims handling in favor of a blended approach that incorporates anti-fraud activities in the core process. This change has been a long time in coming, as many of the core process deficiencies that facilitate health care fraud have been publicized for years, perhaps best articulated by Harvard’s Malcolm Sparrow in his authoritative work on the subject, License to Steal.