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29-07-2012 | Article

Feds, insurers form league to fight healthcare crime



MedWire News: Move over Batman: the federal Government and the private sector are uniting to fight healthcare fraud.

Kathleen Sebelius, Secretary of Health and Human Services (HHS) and Eric Holder, Attorney General of the USA, announced at a press conference that the HHS, the Department of Justice, and a coalition of other public agencies and private health insurers have formed a partnership aimed at better detection and prevention of fraudulent billings.

"Its goal is to reveal and halt scams that cut across a number of public and private payers. The partnership will enable those on the front lines of industry anti-fraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders. It will help law enforcement officials to more effectively identify and prevent suspicious activities, better protect patients' confidential information and use the full range of tools and authorities provided by the Affordable Care Act and other essential statutes to combat and prosecute illegal actions," an HHS statement says.

The Affordable Care Act (ACA) contains provisions for stiff penalties for offenders convicted of healthcare fraud resulting in more than $ 1 million in losses. The law stipulates penalties for individuals or groups who obstruct audits or fraud investigations, and facilitates Department of Justice investigations into potential fraud or criminal activities in long-term care facilities and other institutions. The law also facilitates recapturing of ill-gotten gains that come at the taxpayers' expense.

Among other initiatives, the partnership will make it easier for government and the private sector to share information about specific scams, billing codes that engender suspicion, and "geographical fraud hotspots" such as South Florida, where investigators have uncovered fraudulent Medicare and Medicaid clinics.

"Another potential goal of the partnership is the ability to spot and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities. A potential long-range goal of the partnership is to use sophisticated technology and analytics on industry-wide healthcare data to predict and detect healthcare fraud schemes," the HHS says.

Some of the nation's largest for-profit and not-for-profit insurers have signed up to the partnership.

By Neil Osterweil, MedWire Reporter