Fighting Health Care Fraud

The Obama Administration has made fighting health care fraud one of our top priorities.  In Medicare and Medicaid, these efforts are already paying off.  This year, we announced a record recovery of $4.1 billion in taxpayer dollars. Four years ago, that number was only a little more than $1 billion.

These efforts reflect a broad range of steps we have taken to improve our ability to detect and go after fraud.  For instance:

•             Under the Affordable Care Act, we have new authorities to fight fraud.  This includes additional scrutiny for higher risk categories of providers and suppliers before they’re able to bill Medicare, Medicaid and the Children’s Health Insurance Program (CHIP); and new authority to suspend payments during the investigation of fraud.

For example, this week we suspended payments to home health providers in Texas related to a recent fraud bust.

•             We’ve instituted tougher new rules and sentences for criminals.  From 2008 to 2011, there has been a 75 percent increase in individuals charged with criminal health care fraud.

•             We are implementing a ground-breaking Healthcare Fraud Prevention Partnership, where the federal government and private and state organizations, including insurers, work together to prevent health care fraud.

•             And we have implemented a new Fraud Prevention System that uses predictive modeling technology, similar to the technology that credit card companies use to flag suspicious activity, to review medical claims before they are paid.

Today, we released a report on the first year results of the Fraud Prevention System (http://www.stopmedicarefraud.gov/fraud-rtc12142012.pdf). Since the technology was first rolled out in 2011, all Part A and B Medicare claims – over one billion – have run through the system.   In the first year in operation, the system initiated 536 new investigations and helped stop, prevent, or identify an estimated $115 million in fraudulent payments.

We are working to continue improving our system and refine the way we track our results.  Our law enforcement partners have made important suggestions on how to improve our metrics for reporting these savings, and we are working to implement their recommendations.  They agree – this is an important system that will strengthen our efforts to fight fraud, waste and abuse.

Fighting fraud continues to be a top priority for the Administration, and we will continue implementing innovative new approaches that will protect taxpayer dollars.  For more information on our efforts to fight fraud, please visit: http://www.healthcare.gov/news/factsheets/2011/03/fraud03152011a.html.

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