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Provider Health Insurance Fraud Schemes, Settlements Top $310M

According to HealthPayer Intelligence (January 18, 2018) Law enforcement agencies and federal healthcare administrators including HHS, the Office of the Inspector General (OIG), the FBI, and US Attorney's Offices across the country investigated provider healthcare schemes that defrauded Medicare and Medicaid more than $310 million.  The investigations led to criminal charges and one settlement to resolve False Claims Act allegations. Aggressive prosecution involving healthcare fraud perpetrators was a regularity in 2017 and looks to continue throughout 2018.  By the end of 2017, the Department of Justice (DoJ) recovered nearly $2.4 billion from healthcare fraud schemes, which accounted for 64 percent of the DoJ’s entire fraud recovery totals across all industries.  Enforcement agencies have recently charged alleged criminal entities with millions in kickback schemes, medically unnecessary prescribing activities, and unnecessary medical billing practices.  READ MORE

Are we to believe that fraud of this kind is limited to programs such as Medicare and Medicaid?  Of course it isn't.  The question is whether anyone is watching out for fraud related to the commercial insurance market.  Is it in the best interest of the commercial carrier to monitor this type of activity?  Many would say the answer is 'No'.  Hasn't the ACA actually incentivized health insurance carriers to pay out more in claims?  There is a direct relationship between claims, premiums and insurance carrier profits. 

To learn how you can change employee habits with information on price and quality contact GPI today at 516.804.3383 x 1

Posted 3:10 PM

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