Presentation on theme: "Health Care Fraud Investigation Universal Vulnerabilities, Challenges And Opportunities William J. Mahon The Mahon Consulting Group, LLC Health Insurance."— Presentation transcript:
Health Care Fraud Investigation Universal Vulnerabilities, Challenges And Opportunities William J. Mahon The Mahon Consulting Group, LLC Health Insurance Counter Fraud Group Annual Conference November 3, 2011
What Is Health Care Fraud? An intentional/deliberate act Intended to obtain a benefit, or a greater benefit, to which the perpetrator is not entitled Often joined with waste and abuse, but those are not statutorily defined criminal acts Can involve any party within the health care/health insurance system, and professional criminals who target the system.
The WhatU.S., Federal Health Care Fraud 18USC, Ch. 63, Sec Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice 1. To defraud any health care benefit program; or 2. To obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care services, shall be fined under this title or imprisoned not more than ten years, or both.
The WhatU.S., State-Level Health Care Claims Fraud NJ, 1997 Health Care Claims Fraud means making, or causing to be made, a false, fictitious, fraudulent, or misleading statement of material fact in, or omitting a material fact from, or causing a material fact to be omitted from, any record, bill, claim or other document, in writing, electronically, or in any other form, that a person attempts to submit, submits, causes to be submitted, or attempts to cause to be submitted for payment or reimbursement for health care services.
The Who Dishonest patients –Collusion with dishonest providers/criminal schemes –Eligibility/enrollment fraud re: Dependents Dishonest providers (individuals or institutions) Professional criminals/bogus providers Other parties to the system –Dishonest billing services –Dishonest payer employees
The WhyU.S. 2011: $2.7 trillion national health care expenditure –52 % private-sector $$$ –48 % public-sector $$$ SOURCE: Centers for Medicare & Medicaid Services, National Health Expenditure Projections
The Estimated Financial LossU.S. 3% to 10% of total annual expenditure* Translation: $81 billion to $270 billion in 2011 alone * SOURCES: U.S. Government Accountability Office; National Health Care Anti-Fraud Association
2011 U.S. Fraud Spending in Perspectiveat 3% Estimate 1.Hospital$828 Bil +46% 2.Physician/Clinical Svcs.$556 Bil+ 41% 3.Prescription Drugs$275 Bil+ 46% 4.Nursing Home$156 Bil +36% 5.Dental$112 Bil +37% 6.Govt. Public Health$ 85 Bil +58% 7.Home Health Care$ 83 Bil +93% 8.Fraud$ 81 Bil +50% 9.Other Prof. Care (non-physician) $ 75 Bil +42% 10.Research $ 54 Bil +38% 11.Non-Durable Med. Products$ 43 Bil +30% 12.Durable Medical Equipment $ 28 Bil +33%
2011 U.S. Fraud Spending in Perspectiveat 5% Estimate 1.Hospital$828 Bil 2.Physician/Clinical Svcs.$556 Bil 3.Prescription Drugs$275 Bil 4.Nursing Home$156 Bil 5.Fraud$135 Bil 6.Dental$112 Bil 7.Govt. Public Health$ 85 Bil 8.Home Health Care$ 83 Bil 9.Other Prof. Care (non-physician) $ 75 Bil 10.Research $ 54 Bil 11.Non-Durable Med. Products$ 43 Bil 12.Durable Medical Equipment $ 28 Bil
The Collateral DamageUniversal Corruption of patients medical histories Theft of patients finite health benefits Physical risk/harm to patients Medical identity theft
Universal Anti-Fraud Drivers Impact on ever-increasing costs Link to quality of care/patient safety Media awareness and attention Customer awareness and expectations Senior Management awareness and expectations
Worldwide Awareness & Responses HICFG & Global Partners Korea: National Health Insurance Corporation identifies significant provider-fraud problem in early 2000s Africa Samie, who also chairs the South African Insurance Association (SAIA), has expressed an urgent need for industry experts and professionals to address this issue through the recently developed Insurance Crime Bureau (ICB), an independent industry body aimed at curbing and preventing insurance related crime in South Africa. Insurance Times & Investment News, 6/08 AAR Holdings: Kenya, Uganda, Tanzania, Rwanda... Further expansion planned. Post-tax profits amounted to just 150 million shillings in 2009, due largely to the high levels of fraud plaguing the medical insurance sector. Insurance Business Times, 12/10 About percent of all insurance fraud is on medical costs, through the health providers Jagi Gakunju, AAR CEO Middle East Abu Dhabi: 2010 Health Authority audits identify 38 cases of health insurance fraud: Services not rendered, Rx substitution, non-compliant policies & marketing
Insurers Inherent Vulnerabilities Necessary assumption of honesty Number of providers/billers Number of transactions Variances and ongoing evolution in plan/product design Ongoing technological evolution –Less paper, human scrutiny; more auto-adjuducation Fraud perceived as low-risk/high-reward crime
External & Internal Challenges Nature of some frauds far less clear to critical audiences –Many cases inherently more complex, harder to argue and to prove intent Some health insurers wary of alienating good providers Inherent tension between Fraud Investigation and other operating units with potentially conflicting priorities –Claims –Provider Relations –Provider Network Management Lingering misconception that Managed Care eliminates incentives and opportunities for provider fraud Little or inconsistent coordination between private payer and government-plan anti-fraud activities 14
Worldwide Anti-Fraud Challenges Inconsistency/diversity of medical standards, regulatory oversight and enforcement actions across regions and countries Wide variances in procedure costs across regions and countries, with lack of centralized comparative cost data Lack of boots on ground investigative resources in many regions or countries Inevitable advent of fraud related to growing medical tourism trend Emergence of international marketing of health care servicese.g., adverts in U.S. in-flight magazines for South America cosmetic surgery clinics
Plans Greatest Exposure = Provider-Based Frauds Providers (or purported providers) are the focus of 85% or more of payers fraud investigations Provider-fraud tools: –Patient population to exploit –Possible conditions & treatments to bill –Widespread 3rd-party billing authority, even under managed care-oriented system –Patient/provider/payer information = the vital commodity
Most Common Forms of Provider Fraud Billing for services not rendered (c. 25%) Misrepresentation of services provided (c. 35%) Provision of medically unnecessary services (c. 10%)
Common Characteristics Wide range of simultaneous targets –Multiple payers –Private & public plans –Multiple insurance lines Elimination of patients financial interest, or provision of greater financial inducements to patient Often follows new/expanded benefits, new treatments & technologies Occurs across entire provider spectrum
Notable U.S. Hot Spots The Acute Outpatient surgery center schemes (rent-a-patient) Cosmetic surgery schemes Imaging/other diagnostic testing Pain management & related narcotic Rx schemes (pill mills) Neuro/Musculoskeletal one-stop shopping facilities (chiro, PT, massage, acupuncture, orthopedic, neurological, pain management) Common denominators: –Little or no medical necessity –Risk/harm to patients
Less Prominent Frauds The Chronic Evaluation & management upcoding – time bandits –Office visits –Consultations (in- and outpatient) –Emergency evals, including outsource ER staffing/billing Prescription drug diversion – doctor-shopping –Abuse and/or resale of controlled substances – A perfect storm: Narcotics (vicodin, oxycontin, fentanyl, methadone) Sedatives/anxiety drugs (valium, xanax) Stimulants (ritalin, adderall/amphetamine) –Medical-claim cost far exceeds Rx cost –Significant potential liability for Rx payers –Often out of sight/out of mind re: Outsourced to PBM
Trends Worth Watching... More member-inducement schemes –Rx diversion –Diagnostic testing –Cosmetic surgeries/procedures More Rx doctor-shopping, pharmacy frauds & diversions, prescriptions-for-cash schemes More sake of the patient misrepresentations by providers (soft fraud) More identity-theft schemesdata breaches, sale of patient/member info Providers reaching beyond own specialties for new revenue sources Medical spa billing falsifications Aggressive pharmaceutical-industry marketing of financial inducements to privately insured patients Medical Tourism
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Where Were Headed...?
Essentials for Anti-Fraud Effectiveness Understanding of the crime & its impact Appreciation of the plans exposure Creation/articulation of formal policies Support from the plans highest levels Clear strategies & mechanisms for detection, investigation, resolution & prevention (in-house or outsourced) Appropriate perspective: Vast majority are honest, but the dishonest do disproportionate damage
Essentials for Anti-Fraud Effectiveness Emphasis on pre-payment avoidance Allocation of adequate resources Appropriate plan-wide training Education of insureds re: Impact & risks
Stopping Fraud The Fundamentals Detection –High-Tech Claim-system edits Fraud-detection software Sophisticated data-mining –Low-Tech Human claim review Audits Basic data analysis – follow the money –CPA Audits Internal-control vulnerabilities –Benefit Consultants Prudent benefit design and coverage policies
Stopping Fraud The Fundamentals Audit and Investigation –Audits ID discrepancies –Investigations Establish the facts As warranted, support formal allegations of fraud Resolution –Criminal prosecution and/or civil action –Financial recovery –Network sanctions Prevention –Far more beneficial than pay & chase
Prevention = Transaction-Level Tools Translate post-pay audit/investigative findings & knowledge into pre-pay obstacles to fraud (technological and human) –Fraud indicators –Claim-system edits –Specific fraud flags re: providers, diagnoses, procedures, geographic areas, etc. Anticipate impact Anticipate new benefits and potential vulnerabilities/schemes Design and/or amend benefit policies where appropriate
The Bottom Line: U.S. Health Insurers Anti-Fraud R.O.I. Average anti-fraud budget: $1.9 mil. Average savings & recoveries: $12.3 mil. –Widespread average PMPY return:$2.50 –Best operations PMPY return: $7.50 Average R.O.I.: 6.5 to 1 Best operations R.O.I. Exceeds 12 to 1