By Clark J. Bolton
On February 26, 2014, the U.S. Department of Justice (DOJ) issued a health care fraud/waste/abuse (FWA) news release outlining its record-breaking results for fiscal year 2013. The figure was $4.3 billion, and these results were attributed to multiple program integrity initiatives. Contained in the release was praise for the Health Care Fraud Prevention and Enforcement Action Teams (HEAT), as well as DOJ’s focus on False Claims Act (FCA) cases. Near the end of the announcement was a reference to “historic efforts with the private sector to bring innovation to the fight against health care fraud.”
This mention of innovation relies heavily on public-private collaboration with an emphasis on information and data sharing. Notably, there is no universal national database that includes all claims data. From a pure program integrity perspective, this presents a risk since most providers are conducting business with a mix of public-private payers. Thus, the true size and scope of many suspected FWA cases is initially difficult to assess.
The National Health Care Anti-Fraud Association (NHCAA) recognized this vulnerability and took the initiative to address this gap by creating a voluntary self-reporting program in November 2005 and named it the Special Investigation Resource Intelligence System (SIRIS). The concept behind SIRIS was to establish a forum where all interested parties, public and private, simply share basic case-related information. However, many private payers were reluctant to enter provider information into SIRIS. In fact, since its inception, only 40 percent of all private payers contribute information, but 95 percent review the database in an effort to gather intelligence on their cases.
Efforts to foster collaboration between all interested parties took another major step in July 2012, with the launch of the Healthcare Fraud Prevention Partnership (HFPP). HFPP is a joint program overseen by DOJ and the Department of Health & Human Services and takes the concept started with SIRIS and expands it significantly.
Louis Saccoccio, the chief executive officer of NHCAA, testified before a Senate committee in March in support of HFPP. During the hearing on “Preventing Medicare Fraud,” he defined the charter for this new program:
- “To engage in value-added data-exchange studies between the public and private sector partners.
- To leverage analytic tools and technologies against this more comprehensive data set.
- To provide a forum for business and government leaders and subject matter expert members to share successful anti-fraud practices and effective methodologies and strategies for detecting and preventing health care fraud.”
Saccoccio also addressed the issue on the reluctance of private payers to share information. He noted the existence of immunity statutes for reporting fraud to federal officials but none between private payers. Essentially, in his opinion, the lack of immunity inhibits program integrity objectives, and as a result, he urged lawmakers to pass new legislation to expand immunity to resolve this concern.
Ultimately, interested parties know the futility of relying primarily on a traditional fragmented pay-and-chase model. For example, $4.3 billion represents less than 5 percent of the total annual FWA, conservatively estimated at $90 billion. Instead, there is a recognition that an effective program integrity not only includes HEAT and FCA activities but also expands collaboration across public-private sectors. These efforts are centered on a data-driven approach where improper or fraudulent claims are either stopped pre-payment or quickly identified post-payment and recovered. As a result, this movement toward collaboration and data-driven program integrity will continue to expand into the foreseeable future.
