Tuesday, March 13, 2012

Fighting Fraud, Waste, & Abuse

To address the issues surrounding fraud, waste, and abuse in healthcare, the “Alliance for Health Reform” with the support of Centene Corporation sponsored a Capitol Hill briefing on March 5th. The briefing focused on the efforts that Medicaid, Medicare, and the private sector have or will need to put in place to find solutions to deal with this massive problem. For example, just recently, a Texas doctor and five accomplices were arrested and accused of billing Medicare and Medicaid for $375 million over six years as reported in “USA Today”.

In February 2012, Attorney General Eric Holder and HHS Secretary Kathleen Sebelius released the annual “Health Care Fraud and Abuse Control Program” report showing that the government’s healthcare fraud prevention and enforcement efforts have recovered nearly $4.1 billion in taxpayer dollars in FY 2011.

Ed Howard of the Alliance and the briefing’s co-moderator along with Glen Schuster, CMO for the Centene Corporation, introduced Peter Budetti, Deputy Administrator for Program Integrity at CMS. He discussed how the National Fraud Prevention Program implemented in 2011 is able to monitor 4.5 million claims each day using a variety of analytic models.

As Budetti explained, CMS has taken a number of actions. For example, alerts are generated and consolidated around providers and then prioritized based on risks with results available to the CMS Center for Program Integrity (CPI) and to law enforcement partners.

The fraud prevention program is making it easier for honest providers to enroll in Medicare. Very often the process has been slow, cumbersome, and unreliable. Enrollment improvements have taken place and today there is a two-thirds reduction in time to enroll, online enrollment is available, and all enrollees are in the same system which helps to keep all the information up-to-date.

In addition, the enrollment screening process has improved. Today, fraudulent providers and suppliers can be subjected to extensive, risk-based screening through the new Automated Provider Screening (APS) system implemented by CMS in December 2011.

This is accomplished because now medical identities are checked against the compromised numbers database, addresses are checked against valid location databases, and the system is able to check revocations, exclusions, and felony convictions. At this point, CMS can deny suspected individual claims, revoke providers for improper practices, and can work with law enforcement before, during, and after case development.

Additionally, APS can regularly re-screen all information on a provider enrollment application for continue accuracy and able to provide a unified screening process to ensure that all Medicare providers are screened with the same degree of rigor.

Jim Frogue, Founder of the government relations firm FrogueClark, mentioned several pieces of legislation recently introduced in Congress. The “Fighting Fraud and Abuse to Save Taxpayer Dollars” or referred to as the FAST Act was introduced by Senators Carper and Coburn with a similar bill introduced in the House by Congressmen Peter Roskam and John Carney.

Also, the “Medicare Data Access for Transparency and Accountability Act” (Medicare DATA Act) was introduced by Senators Grassley and Wyden. The “Medicare Common Access Card Act of 2011” was introduced by Senators Wyden and Kirk to use the smart card technology currently used in the armed services in the Medicare system.

Looking at the problem from the state viewpoint, Doug Porter, Medicaid Director for the Health Care Authority in the State of Washington presented an update. So far, states are strongly committed to preventing fraud, waste, and abuse but at the same time, states most ensure that all the resources used will produce a positive return on investment.

Fortunately states are becoming more sophisticated in data mining, deploying the technology that is needed, and additionally, states are working to meet the new requirements and cooperating with federal efforts. He also recommends that federal efforts should do what states can’t or don’t do and support states through better funding which means that states need to be able to apply for grants.

William A. Hazel Jr. M.D., Secretary of Health and Human Resources in the Commonwealth of Virginia explained how his state is working on the problem. Virginia conducts extensive prepayment reviews and performs post payment data mining and audits resulting in over 1000 providers being reviewed over the past two fiscal years. The results show over $40 million has been identified as potential overpayments.

Presenting Centene’s preventative approach, Glen Schuster discussed how Centene is using HIT effectively to minimize and prevent fraud and abuse by providing providers with support, sharing information through care coordination, and participating with other Managed Care Organizations in other states.

Schuster reports how one successful Centene program called Centelligence™ decreased trends in doctor shopping for a group of patients overusing narcotics. So far, this program’s successful efforts have shown a 95 percent decrease overusing drugs in South Carolina, 80 percent decrease in Ohio, 90 percent decrease in Florida, and 95 percent decrease in Georgia.

For more information, go to www.allhealth.org.