August 16, 2012

The Government’s New Public-Private Partnership in Tackling Healthcare Fraud – Seeking Prevention Over Punishment

By Marlene Koury

The government has done a good job of late in recovering billions of dollars of fines from a host of companies big and small for committing various acts of healthcare fraud.  The recoveries so far for this year alone have been record-setting, on their way to crossing the $10 billion mark.  And this number is sure to grow even higher as the Obama Administration continues to ramp up its efforts to tackle the estimated $60 billion in healthcare fraud that occurs every year.  The problem is that while the government has become more successful in recovering for losses that have already occurred, it has not been able to crack the code of stopping the fraud from happening in the first place.  See Low Scores for Government Efforts to Clean Up Medicare/Medicaid Fraud.

The Obama Administration hopes that will all change with its recent introduction of a partnership program with a veritable who’s who of private healthcare organizations including America’s Health Insurance Plans, Blue Cross/Blue Shield, Humana, Travelers, UnitedHealth and WellPoint.  (Click here for the government’s press release.)  The government is even bringing the former fraudster Amerigroup into the fold, which tells you how far the government hopes to go with this new fraud-busting effort.  See Partnering With Former Fraudsters ….  The partnership is aimed at sharing information between these private parties and the government in an effort to detect and prevent major healthcare fraud before it happens, rather than punishing fraudsters after the fact.  The partnership also brings together several federal agencies, state officials and a variety of healthcare anti-fraud groups. 

The idea for the partnership originated at a January 2010 government summit on healthcare fraud, where various public and private organizations realized that they were victims of the same healthcare  fraud.  They decided that by working together sharing information on specific schemes, billing codes or geographical hotspots, these types of criminal healthcare scams – often run by major crime rings – could be busted before any losses occurred.  

Health and Human Services (HHS) Secretary Kathleen Sebelius said that the new partnership “puts criminals on notice that we will find them and stop them before they steal health care dollars.”  Toward this aim, one of the partnership’s objectives is to detect what is currently one of the more common schemes involving charges billed to different insurers for care delivered to the same patient on the same day in two different cities.  By sharing claims information, the partnership hopes to immediately detect and stop this type of scheme before payments are made.  Another goal is to use sophisticated technology on industry-wide healthcare data to predict and detect healthcare fraud schemes going forward.     

The public-private partnership is just the latest in the Obama Administration’s efforts to stamp out healthcare fraud.  Over the last three years, with this year in particular, the Administration’s efforts have resulted in record-breaking nine- and ten-figure recoveries.  Just last month, the government secured its largest healthcare fraud recovery in history with its $3 billion fine against GlaxoSmithKline.  See Big Pharma Strikes Again ….  And the government is poised to settle another multi-billion dollar fraud case against Johnson & Johnson.  See Here We Go Again ….  Now, with this new partnership, the Administration hopes that an ounce of prevention will be worth a pound (or billions of dollars as the case may be) of punishment.

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If you would like more information or would like to speak to a member of Constantine Cannon’s whistleblower lawyer team, please click here.