For fraud enforcement, strength in numbers takes on a double meaning

Strength in numbers. It's a tried and true adage that's so universally applicable, it's been used by high-ranking generals as a wartime strategy, or a pack of disgruntled kindergarteners standing up to the schoolyard bully.

For those charged with fighting fraud, it's a maxim that holds true in more ways than one.

Numbers--or more generally, data--have become the building blocks of fraud prevention, detection and enforcement. Both public and private entities are investing in data analytics, technology and software as way to quickly identify and respond to sophisticated fraud schemes. Earlier this month, Richard Statchen, manager of informatics at Aetna, told FiereceHealthPayer: AntiFraud that the key to keeping pace with evolving fraud schemes is ensuring your data is in "good condition," which means making constant adjustments to strengthen those analytics.

But another trend is gaining traction, one that reflects a more traditional "strength in numbers" approach. Collaboration between state, federal and local enforcement entities is becoming a key cog in the wheel, not just at the national level, but within isolated regions and communities throughout the country.

The origins of this approach to fraud prevention can be traced back to 2007, when the federal government rolled out the Medicare Fraud Strike Force in Miami, widely considered the nation's healthcare fraud capital. The new partnership--which consisted of the Department of Justice, the U.S. Attorney's Office for the Southern District of Florida, the U.S. Department of Health and Human Services (HHS), and the Office of Inspector General (OIG)--first made waves when it brought down the owner of a home health company and two pharmacy owners who billed $20 million worth of false prescriptions and durable medical equipment.  

"Our involvement in today's multi-agency anti-fraud effort is a critical part of our continuing resolve to safeguard the integrity of the Medicare program by stopping fraud and abuse," U.S. Attorney R. Alexander Acosta said at the time.

In 2009, the Strike Force was included within the government's Health Care Fraud Prevention and Enforcement Action Team as Strike Force teams eventually expanded to eight other high-risk cities across the country. These efforts have led to more than $10 billion in fraud recoveries since 2008, and the partnerships played a key role in the largest fraud takedown in U.S. history that charged 243 people involved in various schemes.

As the saying goes, imitation is the sincerest form of flattery. Now, more states are mimicking this approach in less prominent areas of the country, where fraud is seen as a local concern, but maybe not a national priority.

In September, David Hickton, the U.S. Attorney for the District of Western Pennsylvania, announced a "homegrown" task force that will partner with the Drug Enforcement Agency, the Food and Drug Administration, the U.S. Postal Service, as well as the University of Pittsburgh Medical Center and Highmark. Hickton indicated that the task force was assembled because requests for HHS and OIG agents went unfulfilled despite a growing threat of fraud in the region. Rather than wait for the problem to metastasize, he opted for a proactive approach.

West Virginia is in the midst of a similar transformation. Earlier this month, the West Virginia U.S. Attorney's Office announced the creation of a new interagency group that would focus on fraud detection using data analytics, led by the state's assistant U.S. attorney.

These regional partnerships are effectively tearing down any remaining silos of fraud enforcement, allowing state and local agencies to interact with one another and share data and tips in a more regimented and impactful way.

When held up against the complex 21st century technology that drives data analytics, these types of initiatves seem stone-age simplistic. In many ways, they are. There is nothing overtly revolutionary about a half dozen public and private partners collaborating under a common directive.

In this case, however, simple is effective. More than likely, these local agencies are already talking with one another on a less formal basis. Creating a task force merely formalizes that relationship, refocuses the efforts of each individual within the collective group and allows everyone to work more efficiently.

It would be nice to see other parts of the country follow in the footsteps of states like West Virginia and Pennsylvania. If regional collaborations can imitate the same approach employed by the Medicare Fraud Strike force, on a smaller scale, both public and private payers will reap the long-term benefits. Coupled with the growing shift toward predictive analytics, it could be a new, reliable formula for effective fraud prevention. - Evan (@HealthPayer)

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