Fraud fighters from around the country gathered at the National Institutes of Health near Washington, D.C. yesterday to focus on taking the fight against health care fraud to the next level. Sponsored by the Departments of Health & Human Services and Justice, the gathering was the first of its kind that brought together federal program managers, private insurers, technology experts and policymakers. More than 300 people attended the event.
The summit featured a good mix of prepared presentations and speeches (including those by AG Eric Holder and HHS Secretary Kathleen Sebelius) along with hands-on breakout sessions that strategized five key areas. A theme throughout the day-long summit was the need for greater information sharing and building more partnerships between public and private sectors. In wrapup remarks, deputy HHS secretary William Corr spoke of the need to create a “national network of collaboration” to further anti-fraud efforts in all sectors.
There was no new ground broken at this summit, but enlightenment was obvious all around as people from diverse areas of the fraud-fighting community were introduced to aspects of fraud perhaps for the first time. The federal government has a vast infrastructure involved in combatting fraud and it seemed some people who should be well acquainted with each other were meeting for the first time. State fraud bureau directors interacted with their federal counterparts. Government representatives traded strategies with private insurers. Many also seemed to learn for the first time that there’s a good deal of health care fraud in the property/casualty sector. During the breakout sessions and during breaks, business cards were exchanged freely and new acquaintances were made. The benefits of such exchanges will never be known, but it can only help.
Appreciation also seemed to grow for the challenges that others face in combatting fraud. Medicare — the 800-pound gorilla of health insurers — faces special obstacles in resisting fraudulent claims. It’s hard to imagine having to process 1.4 million claims a day with a mandate that providers must be paid within 14 to 30 days. And then when a suspicious claim is delayed, a well-connected provider leans on a congressman who then leans on Medicare. Can’t imagine any such scenario in the private sector.
Medicaid — Medicare’s poor cousin out in the states — also faces its own challenges, specially the lack of resources to combat fraud effectively. The federal government demands states crackdown on Medicaid scams, but provides little financial assistance when you consider the potential amount of money lost each year.
But as much as speakers, panelists and participants bemoaned the problem, they also discussed a variety of new solutions and promising ones for the future. Secretary Sebelius talked of combining various government databases into one to allow for in-depth datamining. Simple things such are random visits to durable medical equipment suppliers also are producing solid results. “The day when you could just hang out a shingle and bill Medicare is over,” she said proudly. She also said President Obama’s upcoming budget proposal will include $1.7 billion to combat fraud.
AG Holder recounted a litany of impressive successes in investigating and prosecuting high-level cases during the last year, but said it can only be a start on much more aggressive efforts by the Justice Department. To enhance federal efforts, he said, “we must seek out guidance from the private sector.” Wise words from someone of his stature.
Holder also responded to specific criticism expressed in FraudBlog two weeks ago about the seeming over-reliance on civil settlements instead of criminal sanctions against some of the worst fraud offenders. He revealed that the case in question — Forba Dental Management and its Small Smiles clinics — will include criminal investigations against individual dentists.
There were other eye-opening presentations, including one from a prosecutor in South Florida who discussed how they streamline complex fraud cases into a fast-track system to bring them to fruition in weeks rather than in two to three years they did previously.
A full report of the proceedings will be published soon by the sponsors that hopefully will include recommendations for concrete steps to fulfill the promise of the summit. We also are holding out hope that a formal partnership can be created between private and public sectors that will give guidance to future relationships and create a more permanent and lasting relationship beyond the current administration.
Secretary Sebelius concluded her remarks by saying “the message of this summit to the criminals who steal from health care is: ‘your days are numbered.’” Let’s hope so.
HHS reached out to the Coalition for guidance in planning this summit. We in turn brought in NICB, NHCAA and NAIC as partners in this endeavor. It was an excellent illustration of high-level collaboration that produced solid results. Special congratulations to HHS staff for producing a high-class event. Written presentations and video from the event can be viewed on the government Medicare fraud website.
Insurance fraud will be a topic in movie theaters across America tonight with the premiere of 
Michel De Jesus Huarte of Miami was quite the entrepreneur who set up a chain of medical clinic in southern states. From 2005 to last year, operating out of storefronts and post-office boxes, his clinics rang out more than $100 million in bogus bills for treatment. He pocketed about $25 million from the federal government alone.
InsuranceFraud.org has chronicled the growing practice by scam artists of using kids in fraud schemes, such as the woman from Virginia who staged car crashes with her three young ones in the back seat. The latest case to surface involves systematic corporate greed, using low-income families to rip off Medicaid.
Arsenio Freitas of Billerica, Mass. grew tired of making payments on his 2008 Chevy Silverado so he allegedly asked his cousin Eduino to help him take the vehicle down to his favorite fishing hole and make the Silverado disappear. As the truck slowly submerges in the water, the pair flee the scene. A few minutes later, a passerby notices the truck and calls 911, thinking this could be a tragic accident with lives at risk. According to a 
At a time when many school districts are laying off teachers, cutting back on classes and increasing class size, six districts in Pennsylvania likely will have to come up with several hundreds of thousands of more dollars to pay for workers compensation and liability insurance. The districts in Berks County will have to bear the extra expense because they allegedly were defrauded by a couple of agents to the tune of more than $1 million. The money they dished out for insurance was used by the agents to buy luxury cars, expensive wine and other personal items — while the school districts went bare, coverage-wise.