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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 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 • Examples of health care fraud cases • Health Care Reform’s impact
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
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.
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.
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
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.
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.
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.
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
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
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
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.
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