Senate Judiciary Holds Hearing on Health Care Fraud

by Astrid Fiano, DOTmed News Writer | November 11, 2009

Continuing problems involve the increasing sophistication of criminals committing health care fraud and the increasing involvement of organized crime enterprises. These criminals illegally obtain provider or enrollment information and use the information to submit fraudulent billings to Medicare and Medicaid. Corr says strike forces are aggressively pursuing such criminal organizations and individuals. Other methods being used to combat fraud include additional training provided directly to state governments by the Medicaid Integrity Institute (MII), established in September 2006 to provide quality education on program integrity to State Medicaid employees. Since February of 2007, more than 1,300 State employees have been trained at the MII. The CMS also conducts comprehensive management reviews of each State's Medicaid program integrity procedures and processes on a triennial basis.

Corr noted that Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS or "DME") has particular risk for fraud. The HHS is employing new methods of analysis in using claims data to identify fraud and implementing new prevention techniques. Much of the focus is on suspicious spikes in DME claims. The HHS vigilantly investigates those spikes while also screening DME providers. Corr says through its efforts, the agency is now seeing substantial drops in DME claims in high-risk areas of the country.

Corr feels the competitive bidding for suppliers will be an important tool for preventing fraud, through the use of surety bonds and accreditation. Until DME competitive bidding is fully operational, CMS will focus on Medicare fraud in seven high-risk areas across the country, with increased pre-payment reviews of medical equipment suppliers, and focusing on the highest-billed claims: continuous positive airway pressure (CPAP) devices, oxygen equipment, glucose monitors and test strips, and power wheelchairs - the most lucrative items and at the greatest risk of fraud.

Witness Tony West, Assistant Attorney General, spoke about the Department of Justice's (DOJ) efforts in health care fraud. In particular is the creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) with HHS. The Medicare Fraud Strike Force has been expanded to four localities: Detroit, Houston, Los Angeles and South Florida. This has resulted in several indictments on nearly $100 million in fraudulent billings and schemes. The HEAT team is analyzing Medicare data to identify fraud hot spots and expand operations to those areas. There are also efforts to educate the public about detecting and preventing fraud, including HEAT's website,