In November, the National Health Care Anti-Fraud Association (NHCAA) appointed Katherine M. Leff as chair of its board of directors. Leff, who leads the Special Investigations Unit for CareSource in Dayton, Ohio, brings "36 years of management-level experience in private as well as public sector insurance," according to an NHCAA release.
In the wake of her appointment, Leff (pictured right) spoke with FierceHealthPayer: AntiFraud in an exclusive interview about some of the major fraud concerns she hopes to address in the coming year, as well as the areas of healthcare that are particularly vulnerable to fraud.
FierceHealth Payer: AntiFraud: What to you hope to accomplish over the next year as the chair of NHCAA's Board of Directors?
Katherine Leff: There is so much going on in the fraud space, and there is so much that NHCAA is involved in, and I think it's is going to be a very pivotal year. We have things like the Healthcare Fraud Prevention Partnership, which is a big, big deal. That's moving along, and there will be more involvement in the next year from many other folks.
This is just going to be a great opportunity. There are a lot of things going on with data analysis algorithms and predictive analytics in the prepayment space. A lot of companies are evolving, and they are finding more fraud--and there is more information sharing, so others are finding the same things as well. It's just a great opportunity and great time to be involved.
In addition to that, individual states are doing some big data captures and sharing. Where you don't have the big data aspect with Medicaid as much because each state is different, I'm finding each state is starting to look at that as well. States are much more interested about what they can do. Can they change a law to help us pursue healthcare fraud?
With NHCAA leading this initiative, providing information to the member companies, and providing training seminars, the Health Fraud Prevention Partnership is something were very much involved in and leading with many others. There is just a tremendous opportunity this next year, and we're going to see some major breakthroughs in healthcare fraud identification and investigation.
FHP AF: A lot of what you have mentioned is technology and data-based. What particular fraud issues would you like to focus on in 2015? From what you've said, it sounds like technology and data are going to be big issues.
Leff: I think the data capturing is very big. I know many companies are coming up with different predictive analytics and smart analytics system. What that is going to bring and what that is going to identify is going to be big. Some spaces are looking to combine medical and pharmacy clients. Usually, they sit in two different databases, but if you can combine those and look at those things together, that's going to bring greater awareness and identification.
We still have our ongoing challenges with controlled substances, behavior health and genetic testing. Genetic testing is a big deal. You see the potential of it in the future and you know that healthcare systems are turning to it. Some of this genetic testing is going to be state-of-the-art in the future, but often times when they start hitting our claims systems, they aren't proven technologies and they cost a lot of money. That's a huge concern: Knowing when they are hitting your system, and then doing the research to figure out who they are, what they do, and how valid it is.
We have home healthcare still. It's been on the forefront for many years, and it continues to be there because it's hard and difficult to get in and identify what's going on in somebody's home. The non-English speaking ethnic groups are very vulnerable, and they are easily taken advantage of, but it's also very difficult for us to get into those groups to evaluate and interview and understand what is going on in order to do the investigation.
FHP AF: In general, there has been a push to get home health more involved and keep patients out of the hospital where it's more expensive. At the same time, you have these targeted areas where fraud does occur quite a bit. Is that a balancing act to get home health more involved, but also be aware of those false claims?
Leff: The challenge with home health is trying to figure out the right path. Each case can be very diffent with what approach you're going to take. A non-English speaking group means a very different approach; you have to get many others involved to assist you in that investigation. Every state has different rules regarding family members becoming your home healthcare providers, and that brings a whole different issue into play. Trying to monitor a family member from inside their home; that's very difficult.
Also, with these ethnic groups that don't speak English, they are very vulnerable to people coming to them and saying, "Hey, sign up for Medicaid, give me your ID," and then doing whatever they want with it. They may not even know that services are being billed under their name.
FHP AF: What can insurers do to better identify and prevent fraud? How are they still struggling to do that?
Leff: We do information-sharing groups nationwide. Plus we have a nationwide database that member companies can feed into so you know what the current schemes and investigations are. That's very helpful, but even local state-based regional information-sharing groups are very important to really knowing what is going on in your area.
FHP AF: Are more states getting involved with that?
Leff: Each state does this different ways. Some states do this very well, and they have a lot of information sharing. Some states are still trying to get there and still learning how this can be beneficial to them.
FHP AF: What's the difference between states that are making progress and those that are struggling?
Leff: There are barriers that need to be broken down. When I'm talking about information sharing, I'm talking not just the managed care plans and not just commercial plans, I'm talking worker's compensation, law enforcement, the attorney general's office and the Office of Inspector General sitting around a room and having a discussion. In some states, you still have barriers to talking to non-law enforcement that are being worked through. I've seen tremendous progress in this area, but it can still be challenging.
FHP AF: The Centers for Medicare & Medicaid Services (CMS) recently released a final rule regarding Medicare and Medicaid fraud with the intent to prevent "bad actors." Is this an effective regulation that will help improve fraud efforts going forward?
Leff: I think there are other things that can be done along with it, but any step in this direction is always good from CMS.
We often find, from our perspective, that we can take what we believe is a fraudulent provider out of our network. The government agencies in different states, on the Medicaid side or the Medicare side, take a lot longer to take any action, so there is much impact to that.
FHP AF: You've been in this field for a long time, but you've been with CareSource for the last 9 years. How has fraud prevention evolved over the last decade in your time with them?
Leff: When I first joined CareSource, it was difficult to get data. We had to be in line with everyone else to try and get data from our claims system--and then you spent a lot of time verifying that data and making certain what you had is accurate and correct. You weren't looking at big quantities of data. It was very targeted data.
Now we have predictive analytics systems. We have post-pay systems that are rules-based. At CareSource, we're bringing up a prepay system that is predictive analytics. That will be up in the spring. It's going to look at claims before they go out the door.
Since I've been at CareSource, it's been pay-and-chase. Starting next year, we're still going to be doing some pay-and-chase, becasue some cases require a major investigation and taking back money that is already being paid. But we're going to try and prevent some of those dollars from going out the door to begin with, which will keep more fraudulent billers from going out the door so don't have to expend the effort to try and get it back.
FHP AF: What advice do you have for payers and insurers looking to improve their fraud prevention practices?
Leff: In this last year I've been to different meetings and different states where people say, "There is nowhere to go to find information about healthcare fraud."
I have to beg to differ. That's not true. You need to get involved with organiztions. Of course I'm going to be very biased towards NHCAA, because I think it's a phenomenal organization that trains and educates on the fraud schemes that are happening today, and then you can go back and take a look at data and actually learn how to look at the data, how to analyze the data, and what systems you need. There's just so much there you can learn.
FHP AF: Anything else you want to add?
Leff: It's going to be a great year next year. Some great initiatives are on the table and moving forward, and I think companies are on board, states are on board and CMS is on board. This is an unprecedented time, when everyone seems to be very interested in this space and is looking at ways to put tools in our hands to help move this forward.