Tomorrow’s Supreme Court decision on health care reform likely will have an effect far and wide across how we and generations that follow buy and use health insurance. But no matter how the Supremes rule — whether they uphold the law, toss it completely or something in between — there’s one aspect of health care that likely won’t change much, and that’s the enhanced levels of fraud fighting.
The Affordable Care Act has had a positive impact on anti-fraud efforts in the private and public sectors. And that’s not just because the law contains a few good anti-fraud provisions. But mostly, the law thrusted health care fraud into the spotlight like never before. During the last two years, the focus by payers, law enforcement, legislators, regulators and regular citizens has been intense in understanding health care fraud schemes and applying new tools to effectively prevent, detect and prosecute fraud.
Additionally, collaboration between federal agencies has never been better — and even cooperation with private insurers and state agencies is gaining ground
Much of the good work that has been started by Medicare and other payers will continue no matter what because fraud is now deemed as one of the cost drivers of health care and consensus is anti-fraud efforts must continue to help put downward pressure on rising costs. Simply put, there’s no turning back.
That said, there is a potential loss of momentum in some areas if health care reform is thrown out in its entirety because the law does contain some effective provisions, such as:
• allowing Medicare to pre-screen providers and ban those that likely are fraudulent,
• allowing Medicare to declare on moratorium on specific areas of providers and suppliers if fraud is found to get out of hand,
• ending the current “pay and chase” model by stopping payments to suspected fraudulent providers,
• requiring federal agencies to share claims data, and
• enhancing civil and criminal penalties for fraud.
The law also provides $350 million in new anti-fraud funds, but most of that has already been spent on enhanced technology such as predictive modeling and other analytics.
But still, many of these can and will continue either through regulation, administrative action or a new law, if need be. Combatting fraud is too important. There is no turning back.