Written by Brooke Haycraft, CEMC, CFPC, CPC-H, CPC
The United States government has been committed to curtailing fraud, waste, and abuse across the realm of federal healthcare, since the Health Care Fraud and Abuse Control (HCFAC) Program was implemented in 1997. Since the creation of the HCFAC, more than $27.8 billion dollars has been returned to the Medicare Trust Fund due to the efforts of fraud, waste, and abuse programs.
Health and Human Services (HHS) Secretary Sylvia Matthews Burwell, who serves as director of the HCFAC with Attorney General Eric Holder, were enthused at these findings. “Eliminating fraud, waste and abuse is a top priority for the Department of Health and Human Services,” Burwell announced on March 19. “These impressive recoveries for the American taxpayer demonstrate our continued commitment to this goal and highlight our efforts to prosecute the most egregious instances of health care fraud and prevent future fraud and abuse. New enrollment screening techniques and computer analytics are preventing fraud before money ever goes out the door. And together with the continued support of Congress and our partners at the Department of Justice, we’ve cracked down on tens of thousands of health care providers suspected of Medicare fraud – all of which are helping to extend the life of the Medicare Trust Fund.”
In Fiscal Year (FY) 2014 alone, the government was able to recoup $3.3 billion in taxpayer’s money from healthcare companies and individuals that aimed to defraud federal healthcare programs serving senior citizens, low-income families and individuals on disability. HCFAC has recovered $7.70 for every dollar invested investigating healthcare related fraud and abuse issues, which is roughly $2 higher than the average return on investment (ROI) of this program and its third-highest return EVER since HCFAC began.
Government administration has recently been changing its strategy to tackling abuse in the world of healthcare; instead of hunting down offenders after the potentially fraudulent incidents has taken place, officials are attempting to be pro-active and focus on preventing abuse before it occurs with new anti-fraud tools. A few examples of updated preventative defenses include—
- Centers for Medicare and Medicaid (CMS) now have the authorization to remove providers that abuse the government systems from federal bonus programs and are also able to revoke billing rights of physicians who have a pattern of inappropriate billing.
- CMS is using technology similar to credit card companies to prevent abuse through the Fraud Prevention System. This system applies live, streaming analysis to all Medicare Fee-For-Service claims and helps to pinpoint suspicious billing patterns and prevents payment of these claims before rather than retrospectively.
- The Health Care Fraud Prevention and Enforcement Team (HEAT), overseen by HHS, Office of the Inspector General (OIG) & Department of Justice (DOJ) is also performing something similar to CMS to battle healthcare fraud. The Medicare Fraud Strike Force (a team composed of OIG and DOJ analysts and investigators) are able to investigate and target abuse and fraud schemes through real-time data analysis. In previous years, claim analysis of troublesome providers was performed AFTER claims were reimbursed, resulting in longer waiting periods due to prolonged investigation, research & arrest. Now these suspicious cases are investigated real-time, significantly cutting down on total review time.
Investigating potential fraudulent activity through new technology to prevent waste and abuse before it actually occurs will not only save taxpayers millions of dollars, but also sets the trend for the future of healthcare. What will the savings show at the end of 2015? Stay tuned to find out.