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Health Care Fraud - State of the Union

Health Care Fraud - State of the Union. Darrell Langlois, CPA, CIA, AHFI Blue Cross and Blue Shield of Louisiana Past Chair, National Health Care Anti-Fraud Association. Agenda for Today. Magnitude of health care costs What and where is health care fraud Who is fighting this issue

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Health Care Fraud - State of the Union

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  1. Health Care Fraud - State of the Union Darrell Langlois, CPA, CIA, AHFI Blue Cross and Blue Shield of Louisiana Past Chair, National Health Care Anti-Fraud Association

  2. Agenda for Today • Magnitude of health care costs • What and where is health care fraud • Who is fighting this issue • Examples of health care fraud cases • Health Care Reform’s impact

  3. Magnitude of Health Care Costs • Total health care spend is near 3 trillion • The trend on claims expense is typically 10% • 17 % of Gross Domestic Product or GDP. • System built on trust • Problems compounded by egos and politics

  4. What and Where is Health Care Fraud • Top three fraud schemes are • Billing for services not rendered • Perform three services and bill for four, or • Billing for patients that never show • Billing for non-medically necessary treatment • Billing for procedures that the patient did not need or require medically. • Upcoding of services actually rendered • Seeing a patient for a low level office visit and billing for a high level encounter.

  5. What and Where is Health Care Fraud • Appears in every form of health care reimbursement • Private, State, Federal, self insured, etc. • Government plans tend to be easier targets due to program design (i.e. for the public) • Private plans are still vulnerable due to prompt pay laws, volume of claims and necessary relationships • Also, because the system is built on trust.

  6. Who is Fighting this Issue • FBI, OIG-HHS, OIG-OPM, OIG-DOD, Medicaid Fraud Control Units, DEA, Louisiana State Police, Department of Insurance and depending on charges local District Attorneys • Health Care Fraud is a Federal crime and proceeds funnel to Health Care Fraud Trust Fund • State statutes address as insurance fraud – 2010 Legislative session began to address laws specific to health care fraud. • Create a unique definition

  7. Examples of HCF Cases • Nationally DME Fraud originating from Florida has cost Medicare and several payors nearly $1 trillion. • Stealing physician’s IDs, starting businesses that never sell the first item. • Included items such as insulin pumps, TENS units and high priced drugs • No site visits were conducted before allowing the provider into the process. • Had site visits been performed, much of this could have been avoided.

  8. Examples of HCF Cases • Physician in New Orleans billing six hours for every hour with a patient. • Billed an hour for each staff member regardless of their role. • Pled guilty a few months ago to health care fraud after losses of over $100K.

  9. Examples of HCF Cases • Tracking a neurosurgeon after complaints of medical malpractice. • Over 40 lawsuits pending against this MD • Already settled one for $800,000 • Sanctioned by the admitting hospital and State Board • Nearly $1 million per year in billings, not including hospital costs.

  10. Example of HCF Cases • Intra-operative Monitoring provider • A tech in the O/R places leads on patient to detect nerve damage during surgery • Supposedly an MD monitors remotely (sometimes 1000’s of miles away) to inform the surgeon of any potential harm • Their own statement was that they could perform 24 simultaneously with one MD

  11. Example of HCF Cases • Worked hard to convince law enforcement to work the case • Eventually a whistleblower came forward • 30 agents executed a search warrant • Found records of non-medical staff monitoring • Forged record • Admitted to child porn on computers

  12. Impact of Health Care Reform • HCF is a major focus, largely addressed for Gov’t plans and law enforcement • Increase communication between gov’t and private payers as all pay for fraud • Increase in Individuals committing fraud • Removing Pre-existing • Penalties for not purchasing insurance

  13. National White Paper • The sharing of anti-fraud information between private insurers and government programs should be encouraged and enhanced. • Data consolidation and real time data analysis must be at the forefront of health care fraud detection and prevention. • Pre-payment reviews and audits should be increased and strengthened. • Public and private health plans should be allowed to protect their enrollees by barring or expelling providers suspected of perpetrating health care fraud. • Health care providers participating in fraud should be sanctioned by their respective state licensing boards. • Health care provider identifier numbers should be made more secure. 7. Investment in innovative health care fraud prevention, detection and investigation efforts and programs should be encouraged.

  14. Health Care Fraud Questions

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