November 20, 2012 News

Joint Initiatives to Reduce Health Care Fraud

The federal government, state officials, several leading private health insurance organizations, and other health care anti-fraud groups have joined in a partnership to reduce fraudulent Medicare and Medicaid payments.

Under the voluntary collaboration, announced in July, partners can share information and best practices to improve detection and prevent payment of fraudulent health care billings, with the ultimate goal of revealing and halting scams. It will help law enforcement officials identify and prevent suspicious activities, protect patients’ confidential information, and use all legislative provisions to combat and prosecute illegal actions.

In one program, partners will share information on specific schemes, billing code usage, and geographical fraud hotspots to prevent losses to government and private health plans. Another potential goal is to identify and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities. A potential long-range goal is to use sophisticated technology and analytics on industry-wide health care data to predict and detect health care fraud schemes.

The partnership builds on additional tools provided by the Affordable Care Act, which was upheld by the Supreme Court in June. In addition to creating health insurance exchanges and expanding Medicaid, the law improves and expands consumer protection and reduces costs through several initiatives, including government-wide efforts to fight fraud and waste.

Speech-language pathologists have recently seen results of these efforts, including the arrest of SLPs in Florida (more than $2 million in fraud) and a North Carolina SLP who pleaded guilty to Medicaid fraud ($360,000 in fraud). Charges included allowing speech-language pathology assistants to provide unsupervised treatment to Medicaid recipients and filing false claims.

The law authorizes stronger civil and monetary penalties on those found to have committed fraud and prevents problematic providers from participating in Medicare or Medicaid.

The new initiatives include:

  • Tough new rules and sentences for criminals. Federal sentencing guidelines for health care fraud offenses increase 20%–50% for crimes that involve more than $1 million in losses. Providers who identify an overpayment from Medicare or Medicaid but do not return it within 60 days may be subject to new fines and penalties.
  • Enhanced screening and other enrollment requirements. New requirements for providers and suppliers wishing to participate in government programs include a higher level of scrutiny in licensure checks and site visits to verify provider identity. Providers and suppliers who lie on their Medicare or Medicaid enrollment applications may be excluded from the programs.
  • Allowance for a temporary moratorium on newly enrolling providers. The state government in certain geographic areas (known as fraud hotspots) may prevent new providers from enrolling until current providers demonstrate regulatory compliance.
  • Increased coordination of fraud prevention efforts. States must withhold payments to Medicaid providers for whom there is a pending investigation of a credible allegation of fraud, and can prevent enrollment of new providers.
  • Collaboration with the Health Care Fraud Prevention and Enforcement Action Team (HEAT). This joint effort between Health and Human Services and the Department of Justice ensures that providers who are terminated from Medicare, a state Medicaid program, or both will be terminated from Medicaid programs in other states.
  • Use of state of-the art fraud detection technology. Much like the predictive technologies used in the credit card industry, the Fraud Prevention System uses advanced technology to identify suspicious behavior and billing irregularities.
  • Greater oversight of private insurance abuse. The new law also provides enhanced tools and authorities to address abuses and protect employers and employees from insurance scams and gives Health and Human Services the power to investigate and audit health insurance exchanges. This oversight, coupled with new rules to ensure accountability in the insurance industry, will protect consumers and increase the affordability of health care.
  • New funding resources to fight fraud. The Affordable Care Act provides an additional $350 million over 10 years to increase anti-fraud efforts, including greater scrutiny of claims before they are paid, investments in sophisticated data analytics, and an increased manpower to fight fraud in the health care system.

For more information, view the news briefing.

Laurie Alban Havens, MA, CCC-SLP, director of private health plans and Medicaid advocacy, can be reached at

cite as: Havens, L. A. (2012, November 20). Joint Initiatives to Reduce Health Care Fraud. The ASHA Leader.


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