Health Information Exchange Featured Article

February 11, 2013

Obama Administration Cracks Down on Healthcare Fraud

Between its anti-fraud task force and the Affordable Care Act, the Obama Administration has recovered $15 billion lost to healthcare fraud over the past four years.

Last year, the Department of Health and Human Services (HHS) and the Justice Department recovered $4.2 billion thanks to healthcare fraud investigations. The Obama Administration boasts that its recoveries are double those of the previous administration.

“Our historic effort to take on the criminals who steal from Medicare and Medicaid is paying off,” said HHS Secretary Kathleen Sebelius. “We are gaining the upper hand in our fight against healthcare fraud.”

The federal government reportedly recovers $7.90 for every dollar that it spends on healthcare fraud investigations.

In a statement, the Obama Administration credited both Affordable Care Act provisions and its Healthcare Fraud Prevention and Enforcement Action Team (HEAT).

HEAT lists some of the top causes of healthcare fraud. These schemes include billing for services that were never provided or billing for a service that costs more than what was actually provided.

Sketchy providers also falsify a patient’s diagnosis to justify expensive tests. Cosmetic surgeons, for instance, may bill insurance companies or Medicare for a deviated septum operation when the patient simply wanted Rihanna’s nose.

Sometimes, providers overcharge patients for co-pays. Alternatively, they tell the patient that no co-pay is needed so that they can overbill the insurance company.

Between HEAT and “Obamacare,” officials have new tools to stop the abuse of the country’s healthcare system. For crimes that involve over $1 million in losses, perpetrators will get 20 to 50 percent longer sentences.

The Centers for Medicare & Medicaid Services (CMS) have started running fee-for-service claims through state-of-the-art fraud detection technology. The CMS is also screening suspect providers more strenuously by conducting site visits and licensure checks.

Providers may also be fingerprinted for criminal background checks.

In addition, the Obama Administration has increased funding for Senior Medicare Patrols. These senior volunteers educate their peers and elderly caregivers about how to identify, report and prevent healthcare fraud.

While determining the exact amount of money lost to healthcare fraud is difficult, Attorney General Eric Holder has estimated $60 to $90 billion in annual Medicare fraud.

He suggests a similar amount for Medicaid.

Edited by Braden Becker