Consortium to Combat Medical Fraud
Mission
The consortium is a joint project of the Coalition Against Insurance Fraud, the National Health Care Anti-fraud Association and the National Insurance Crime Bureau. Participants include these three organizations , their member insurance companies, state insurance fraud bureaus and representatives of the FBI.
Background
Fraud committed by unethical medical providers in the United States continues to total tens of billions of dollars each year. Perpetrators range from organized criminal enterprises that stage auto accidents to surgical centers that perform unneeded operations to family physicians that occasionally bill for treatment not provided. Fraud is a continuing problem in virtually all segments of medicine, including diagnostic centers, durable medical equipment supplies, pharmacies and medical transport companies.
Medical providers defraud all segments of the insurance industry that provide compensation for illness and injury, including health insurance, auto insurance carriers, workers compensation and disability insurance. Yet, there has been little coordination among the various segments to share intelligence, strategies and training involving fraud by medical providers. The Consortium to Combat Medical Fraud seeks to close these gaps.
Mission
To move from a specific industry approach to creating a national agenda to combat medical fraud for public and private benefit by unleashing our collective resources by:
• Sharing information across industry and stakeholders
• Increase awareness among stakeholders
• Leveraging best practices
• Influencing public policy and shaping agenda
• Optimizing and aligning objectives of various associations
Through legislative/regulatory efforts, task forces and other cooperative efforts and joint public outreach.
Projects
1 - Existing program activities include developing enhanced training to help property/casualty insurance investigators and health insurance investigators learn techniques and strategies employed by the other side, and to encourage cooperation across lines of insurance in detecting and investigating fraud by medical providers. Additionally, individual insurers and payers are encouraged to reach out to non-traditional industry allies to help build cases against fraudulent medical providers.
2 – Cross-matching data on provider investigations between databases maintained by the property/casualty and health insurance industries has helped insurers better detect fraudulent schemes and cooperate in building cases against suspect providers.
3 – A research project is planned for later this year that will focus on gathering information on state medical boards to evaluate how well they are disciplining licensees who commit fraud.
