Seeing the whole problem: An elephant story for fraud fighters

Six blind men lived in a village visited by an elephant. They had no idea what an elephant was, and so they--being curious and bold--decided to touch the animal to find out. (Note to readers: Do not attempt this at home.)

"It's like a pillar," said the man who touched the elephant's leg.

"No, it's more like a fan," said the man who touched its ear.

"It's like a spear," said the man who touched its tusk.

"Wrong! It's like the branch of a tree," said the man who touched the trunk.

"I think it's like a rope," said the man who touched the tail.

They began bickering. The story ends with a reminder that though each man was partly right, all of them missed the whole.

Healthcare fraud can be like a visiting elephant. Fraud is a large, moving problem. Just as an elephant has many parts, health insurance fraud has many entry points. Fraud schemes can turn out to be far more layered and complex than analysts initially assume. Some fraud fighters work like the blind men who know what's before them but miss the totality of the threat. And anti-fraud professionals haven't always shared resources and experiential knowledge to understand what they're facing and act accordingly. But that's changing.

The federal government's release of Medicare provider payment data, for instance, has prompted analyses that brought wild and wooly claims patterns to light.

Big data tools are helping us crack the puzzles of the unknown. The Medicare Fraud prevention system, for example, harnessed the power of predicative modeling to fight fraud. The system exposed or prevented about $115 million in overpayments in its first year of use, as FierceHealthIT reported. And an Office of Inspector General report published last month stated that using the system led to $54.2 million in actual and projected savings for traditional Medicare.

Here's more encouraging news: The Centers for Medicare & Medicaid Services is converting high volumes of raw data into actionable information and working to share it securely. Besides claims data, CMS collects surveys, quality information, beneficiary assessments, Medicare Advantage encounter data and prescription drug events. Taken together, these can provide fraud fighters with a more whole-seeing picture of patients and providers in various care settings across time.

And CMS is starting to integrate its data by moving them out of incompatible systems. Think of the implications of this for Medicare and Medicaid integrity. How many times has one of these programs been bilked by a fraud scheme that showed up in the other?

Also consistent with the theme of seeing the whole, efforts are underway to increase use of prescription drug monitoring programs and make them national in scope to thwart doctor shopping.

Anti-fraud experts give loads of operational advice aligning with moral of the elephant's tale: Leave your silos, they say, and start collaborating.

It's a mistake for SIUs to be too insular and lack strong working knowledge of the rest of their organization and the investigative community, Deloitte's Mike Little told FierceHealthPayer: Anti-Fraud in an exclusive interview. He encourages special investigations units to plug into a healthcare fraud task force and work closely with federal and state regulators. "These groups are the wave of the future in terms of public and private partnerships," Little said.

The U.S. Department of Health and Human Services and the U.S. Department of Justice, for example, launched one such partnership to improve detection and prevent payment of fraudulent claims by public and private payers. DOJ trial attorney Rebecca Pyne advised insurers to consider joining.

Fraud investigators should commit to engaging with law enforcement at all levels, according to Aetna's Ralph Carpenter. Boston FBI Supervisory Special Agent Christine O'Neill recommends that payer SIUs and law enforcement agents meet quarterly.

And payers should make early contact with law enforcement on potential fraud cases, Assistant U.S. Attorney Ted Radway counseled.

"We have tools the special investigations units don't," Radway said. "For example, we can conduct undercover operations and recover financial assets. But this also goes the other way: SIUs can have access to information law enforcement doesn't have, such as beneficiary complaints and documentation of provider contacts and education."

Overall, health insurance programs have been feasts for thieves due to fragmented efforts to stop them and schemes we don't see. Better collaboration and information sharing will help fraud fighters recognize and respond more effectively to the great pachyderm before us. - Jane (@HealthPayer)

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