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Medical Coding News Archives

Health Care Recoveries in 2012 Break Record

 
February 21, 2013:

Trudy Whitehead, CPC-H, CMAS, Clinical/Technical Editor

A report released on February 11 shows that the federal government recovered $4.2 billion in 2012 in payments due to health care fraud and abuse. This is an increase over $4.1 billion of recoveries in fiscal 2011. The return on investment over the past three years—$7.90 for every dollar spent on health care-related fraud and abuse investigation and represents the greatest three-year return—is the highest in the 16-year history of the Health Care Fraud and Abuse (HCFA) program.

Companies and individuals seeking undeserved payments by attempting to defraud federal health programs that serve seniors and taxpayers were responsible for the overpayments. The Obama administration’s prioritizing the elimination of fraud, abuse, and waste, particularly in health care, is credited with leading to the large recovery amount. The Affordable Care Act has fostered increased data sharing across the government, enhanced screenings and enrollment requirements, greater oversight of private insurance abuses, and expanded recovery of overpayments.

The Health Care Fraud Prevention and Enforcement Action Team (HEAT) was developed in 2009 in an effort to prevent fraud, abuse, and waste in the Medicare and Medicaid programs and to crack down on individuals and entities that abuse the system. Coordinated efforts through HEAT have helped educate Medicare beneficiaries about how to protect themselves against fraud.

Advanced data analysis techniques identify health care fraud hot spots. This allows interagency teams to target emerging or migrating schemes along with chronic fraud by criminals who pose as health care suppliers or providers. To help in this effort, the federal government launched in July a partnership with private health insurance organizations and state officials to share information and best practices to help detect and prevent payments due to scams.

In fiscal 2012, the Department of Justice opened 1,131 new criminal health care fraud investigations and 885 new civil investigations, and 826 defendants were convicted of health care crimes.

CMS began screening all of the 1.5 million providers enrolled in Medicare through the new Automated Provider Screening system, which identifies ineligible and potentially fraudulent suppliers and screens suppliers before enrollment or revalidation. This led to the elimination of almost 150,000 ineligible providers from Medicare’s billing system.

Civil health care fraud enforcement efforts continued through the Department of Justice and Department of Health and Human Services under the False Claims Act (FCA), resulting in settlements and judgements of more than $3 billion in fiscal 2012 under the False Claims Act. Violations included illegal marketing of medical devices and pharmaceutical products for uses not approved by the Food and Drug Administration, Medicare fraud by hospitals and other institutional providers, unlawful pricing by pharmaceutical manufacturers, and violations of laws pertaining to self-referrals and kickbacks.

 

 
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