The same criminals who run medical fraud schemes on health insurers and government health programs often ply their trade on property/ casualty and workers compensation carriers. Last week, the full array of victims announced that theyve combined forces to defend themselves.
The new Consortium to Combat Medical Fraud merges the resources of the National Health Care Anti-Fraud Association, or NHCAA; National Insurance Crime Bureau, or NICB; Coalition Against Insurance Fraud; FBI; and the fraud section of the Justice Departments criminal division.
The NHCAA since the mid-1980s has developed a deep database of information from fraud investigations conducted by its members, which include nearly 100 health insurance companies as well as a few dozen federal and state agencies. With the new alliance in place, the organization is prepared to share the information with its peers to find out whether the same perpetrators are submitting bogus medical claims to other types of insurers, said Executive Director Louis Saccoccio.
If theyre committing fraud on one side, are they committing fraud on the other side? Saccoccio said. He added that the collaboration, which will include joint education programs across insurance lines, should help those companies and groups on the other side who are not as familiar looking at medical claims and identifying items likely to have been upcoded or never provided.
The health insurance companies, Saccoccio said, stand to gain an advantage over the fraudsters by building stronger cases against them. Sometimes its a matter of aggregating damages and losses. The bigger the case it is, the better.
The NICB, which investigates fraud with the help of law enforcement and insurance companies, has increasingly targeted medical fraud since establishing task forces for that purpose in New York City and South Florida in 2002. Others have been added in Houston, Los Angeles and the Washington area, along with about 30 smaller-scale efforts throughout the country.
What we have seen is tremendous crossover, said Gary Healy, Mid-Atlantic director of operations for the NICB. Healy said that the industry has estimated that 10% of premiums consumers pay for their policies goes toward claims determined to be medical fraud.
We have organized rings that go out and literally stage accidents, Healy said. Its a drain on the healthcare system, and the whole things a setup. The schemes require the participation of medical providers who submit claims to a variety of payers theyve chosen as their marks. Another endeavor of the consortium will be industry research, and the first project to be studied, the participants say, is the level of discipline meted out by state medical boards to physicians who commit fraud.