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Homecare Software Blog – DOJ Shifts Battle in Fighting Medicare/Medicaid Fraud to Prevention

“According to DOJ estimates, the Administration recently has recovered more than $7.00 for every dollar spent combating health care-related fraud and abuse”

June 6, 2015- Media outlets are reporting that upwards of $27.8 billion dollars has been returned to the Medicare Trust Fund since the Health Care Fraud and Abuse Control (HCFAC) Program instituted by former Attorney General Eric Holder & HHS Secretary Sylvia M. Burwell has been active. The U.S government’s health care fraud prevention and enforcement efforts brought back $3.3 billion in taxpayer dollars last year from individuals and businesses that attempted to defraud federal health programs. These programs were serving seniors, persons with disabilities, or those with low incomes.

These recent recoveries are the result of a two-pronged strategy to do away with fraud and abuse in the home care sectors and beyond. With many new rules in effect under the Affordable Care Act, the administration seems more focused on the implementation of programs that abandon the “pay and chase” efforts of the past, which largely targeted those who had already defrauded the government seeking to retrieve funds. The new ideology seems to be honed in on preventing health care fraud and abuse before it actually happens. Additionally, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), has significantly changed how the federal government combats many types of health care fraud. Most current cases are investigated through real-time data analysis instead of the usual prolonged subpoena and account analysis tendencies of the past. This has yielded much shorter time between fraud identification, arrest, and ultimately prosecution and recovery of funds.

Technology in Play

Much like the technology used by credit card companies, CMS has been using its Fraud Prevention System to apply advanced analytics to Medicare Fee-For-Service claims on a streaming, nationwide basis. The Fraud Prevention System automatically identifies aberrant or suspicious billing patterns, which triggers actions that can be implemented swiftly to prevent payment of fraudulent claims.

On the state level, many states have also mandated that Homecare Telephony Software be utilized for all Homecare visits, verifying the caregiver actually arrived at a patient or client’s home and rendered services, a huge step in the prevention of false claims and other methods of fraud.

In certain states such as Florida, there is a high concentration of fraud in the Healthcare industry. Earlier this week, Attorney General Loretta E. Lynch & Department of Health and Human Services (HHS) Secretary Sylvia Mathews Burwell announced that a nationwide sweep led by the Medicare Fraud Strike Force in 17 districts, resulted in charges against 243 individuals, inclusive of 46 doctors, nurses and other licensed medical professionals for their alleged participation in Medicare fraud schemes involving more than $710 million dollars in false billings. In addition, the Centers for Medicare & Medicaid Services (CMS) also suspended a number of healthcare providers using suspension authorities granted within the Affordable Care Act. This coordinated effort is the largest ever conducted, both in terms of the number of defendants charged and the amount of combined losses.

Attorney General Lynch and Secretary Burwell were joined in the announcement by FBI Director James B. Comey, Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, Inspector General Daniel R. Levinson of the HHS Office of Inspector General (HHS-OIG) and Deputy Administrator and Director of CMS Center for Program Integrity Shantanu Agrawal, M.D.

The defendants involved were charged with a number of health care fraud-related crimes, many being in the home health care industry. These charges include conspiracy to commit health care fraud, violations of the anti-kickback statutes, money laundering and aggravated identity theft.

In Miami, Florida alone, a total of 73 defendants were charged with offenses relating to their participation in numerous fraud schemes involving more than $262 million in false billings for home health care, mental health services and pharmacy fraud. The nationwide sweep netted hundreds of charges in Texas, California, Michigan, and many other states.

For more information on utilizing Home healthcare Software technology for fraud prevention, email us at Info@Alorahealth.com

The Alora Homecare Software Blog

Read the Alora blog to learn more about the Home Health Software industry, including recent news, articles and commentaries, as well as other issues that pertain to Homecare in the U.S and beyond. For more information on our blog, or for questions or feedback, please send us an email to HomeHealthSoftware@AloraHealth.com.