The partnership arose from the Coalition Against Insurance Fraud’s offer to HHS to coordinate a health care fraud summit in 2010,3 and is further evidence of the Obama administration’s full-throttle effort to reduce fraud and abuse in health care, and to recover public and private losses in the industry. The partnership complements, and in many ways is a natural extension of, the ever-escalating anti-fraud efforts, including increased criminal prosecutions, civil lawsuits, the recently implemented Stark Self-Referral Disclosure Protocol, and the Patient Protection and Affordable Care Act’s provision for longer criminal sentences for certain categories of health care fraud.
Prosecuting fraud and abuse has been a state and federal government priority for several years, and diligent health care providers and suppliers have implemented their own anti-fraud programs and compliance plans. With growing public/private resources and fewer barriers to information-sharing, providers and suppliers should anticipate more scrutiny of all claims — whether they are sent to public or private payers. The government’s best options for pursuing non-governmental health care fraud include criminal prosecutions under a variety of theories. While the government could always pursue private actors, it has sometimes been stymied by a lack of access to data, documents, and witnesses. By working with private entities, the executive branch likely hopes to expand its fraud-fighting toolkit even more. For their part, the private partners’ voluntary participation is likely seen as a commitment to joining the government’s battle. This partnership, especially when viewed as one more arrow in the government’s quiver, suggests that all providers and suppliers — irrespective of their payer mix — will need to focus on, and obtain management buy-in for, careful monitoring to assure compliance with fraud and abuse laws. In sum, with more entities joining the fight against fraud and abuse, it may be getting harder to stay beneath the government’s radar.
1The following organizations and government agencies are members of the partnership: America’s Health Insurance Plans, Amerigroup Corporation, Blue Cross and Blue Shield Association, Blue Cross and Blue Shield of Louisiana, Centers for Medicare & Medicaid Services, Coalition Against Insurance Fraud, Federal Bureau of Investigations, Health and Human Services Office of Inspector General, Humana Inc., Independence Blue Cross, National Association of Insurance Commissioners, National Association of Medicaid Fraud Control Units, National Health Care Anti-Fraud Association, National Insurance Crime Bureau, New York Office of Medicaid Inspector General, Travelers, Tufts Health Plan, UnitedHealth Group, U.S. Department of Health and Human Services, U.S. Department of Justice, WellPoint, Inc. “Obama Administration Announces Ground-Breaking Public-Private Partnership to Prevent Health Care Fraud,” Department of Health and Human Services (July 26, 12).
2“A new partnership,” Coalition Against Insurance Fraud, available at http://www.insurancefraud.org/blog/?p=1756 (July 26, 12).
Torrey K. Young
Lisa M. Noller
Judith A. Waltz
San Francisco, California
Maria E. Gonzalez Knavel
Michael Scarano, Jr.
San Diego, California