Healthcare fraud doesn't discriminate--it doesn't matter whether the payer is public or private.
"Fraudsters will play with whoever will pay," Jennifer Trussell, special advisor with the Office of Investigations at the Office of Inspector General, told an audience at the National Health Care Anti-Fraud Association (NHCAA)'s Annual Training Conference in Orlando, Fla.
As a result, the federal government and private health insurers must team up to fight fraud, and keep several emerging trends on their radar. For instance:
- Government and private payers must adapt to evolving healthcare fraud activity, from simple upcoding to criminal enterprises. And fraud investigators now must look out for sophisticated schemes in which patients actually receive (sometimes needed) services--which could slip through fraud data nets, Trussell noted.
- Fraud investigators must also watch for emerging Affordable Care Act scams, such as copycat HealthCare.gov sites and medical identity theft.
- The increasing adoption of electronic health records has led healthcare into an era of "perfectly documented fraud," according to Trussell. Many EHR systems, for example, allow autopopulation to automatically check what the clinician did to make the diagnosis and uncheck what he or she didn't do. And some software doesn't include audit trails."So you don't know whether the doctor checked or unchecked, whether it was the biller, the receptionist or some guy on the street," Trussell said.
- Medicare Part B billing has been growing slow and steady. Trussell pointed out several areas responsible for the uptick that need more attention from fraud investigators. Emerging schemes include medically unnecessary heart stents in cardiology, or dermatologists performing cosmetic procedures billed as precancerous lesions.
- What' really catching Trussell's attention is diagnostic testing in general and genetic tests in particular--which patients usually don't need and come with a $1,000-price tag. What's more, the testing companies are targeting outside the clinical area, socially engaging people at malls, for example.
- Sleep studies also deserve increased attention, as Medicare Part B billing for these services jumped 40 percent in the past five years, Trussell told the audience.
- On top of all these healthcare fraud hot spots, Medicare Part C, Medicaid managed care and Medicare managed care keep Trussell up at night. That's because managed care is a blind data spot and investigators can't see the big picture in the data.
"You've seen Medicaid managed care in one state, you've seen it in one state. And good luck getting the states' data to talk," Trussell said.
But with emerging--and evolving--healthcare fraud schemes, payers must use whatever data they have to enhance investigations and prevention efforts, Trussell advised--be they complicated algorithms or excel spreadsheets.