Affordable Care Act Fighting Fraud

By Editor • April 4th, 2012

SOURCE: www.hhs.gov

New tools provided by the Affordable Care Act to fight health care fraud.  As a result of Affordable Care Act provisions:

  • Criminals face tougher sentences for health care fraud, 20-50 percent longer for crimes that involve more than $1 million in losses;
  • Contractors that police Medicare for waste, fraud, and abuse will expand their work to Medicaid, Medicare Advantage, and Medicare Part D programs;
  • Government entities, including states, the Centers for Medicare & Medicaid Services (CMS), and law enforcement partners at the Office of the Inspector General (OIG) and DOJ, have greater abilities to work together and share information so that CMS can prevent money from going to bad actors by using its authority to suspend payments to providers and suppliers engaged in suspected fraudulent activity.

Today, the Obama administration also announced more progress from its anti-fraud efforts, beyond the nearly $4.1 billion recovered last year:

  • In the early phase of revalidating the enrollment of providers in Medicare, 234 providers were removed from the program because they were deceased, debarred or excluded by other federal agencies, or were found to be in false storefronts or otherwise invalid business locations;
  • In 2011, HHS revoked 4,850 Medicaid providers and suppliers and deactivated 56,733 Medicare providers and suppliers as it took steps to close vulnerabilities in Medicare;
  • In 2011, HHS saved $208 million through pre-payment edits that stop implausible claims before they are paid;
  • Prosecutions are up: the number of individuals charged with fraud increased from 797 in fiscal year 2008 to 1,430 in fiscal 2011 – nearly a 75 percent increase;
  • In the first few weeks of enhanced site visits required under the ACA screening requirements, HHS found 15 providers and suppliers whose business locations were non-operational and terminated their billing privileges;
  • Through outreach and engagement efforts more than 49,000 complaints of fraud from seniors and people with disabilities reported to 1-800-MEDICARE were referred for further evaluation;
  • A recent re-design of the quarterly Medicare Summary Notices received by Medicare beneficiaries makes it easier to spot and report fraud.

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