Healthcare fraud is a seemingly overwhelming problem. Large healthcare companies perpetrate systematic schemes, while corrupt practitioners and common criminals steal funds through hoaxes involving phony clinics, phantom patients and billing for services and medical equipment never provided.
Most important, healthcare fraud can injure patients. No clearer example exists than the Michigan oncologist recently sentenced to 45 years in prison for giving false cancer diagnoses and providing unnecessary and dangerous treatments to collect millions of Medicare dollars.
During my years as the chief Obama administration official responsible for fighting healthcare fraud at the CMS, I saw the challenges firsthand. They are big, but not insurmountable.
The answer lies in changing the paradigm, the anti-fraud infrastructure and the technology for fighting fraud as well as strengthening the reward system to encourage those with information about healthcare fraud to step forward.
The paradigm, rightly dubbed “pay and chase,” has been to pay claims quickly, then search for discrepancies after the fact. But this approach has a fatal flaw. As a takedown in June of more than 240 healthcare professionals in 17 cities showed, arrests generally do not happen until hundreds of millions of dollars in false billings have occurred. By then, the money has usually disappeared. Moreover, “pay and chase” addresses fee-for-service fraud, while novel schemes are emerging in Medicare Advantage and prescription drug plans and innovative funding arrangements such as accountable care organizations. A congressional hearing just last week focused on these issues.
The new approach must be one of preventing fraud from occurring in the first place, or detecting and stopping it early. Yet, that shift is not easily accomplished.
“Pay and chase” relies on an entrenched enforcement infrastructure built to carry out investigations and develop cases for prosecution. Prevention and early detection, on the other hand, require costly and complicated advanced technology and analytics that screen real-time claims data to spot and cut off fraudulent claims before they are paid.