Home Health & Hospice Week

The government's stepped-up efforts in the fraud and abuse arena are bearing fruit, but innocent providers hope it isn't at their expense.

"This has been a remarkable year for cracking down on health care fraud," says Health and Human Services Secretary Kathleen Sebelius in a statement released at the 4th regional healthcare fraud prevention summit held in Boston Dec. 16. "Thanks to the new tools and resources provided under the Affordable Care Act, we are more effective at going after the fraudsters that are stealing taxpayer dollars."

Massachusetts alone has recovered more than $4 billion in civil and criminal healthcare fraud settlements over the past two years, notes Attorney General Eric Holder in the release. "We have taken our fight against health care fraud to a new level, and I am committed to continued collaboration, vigilance, and progress."

Medicare and other federal programs plan to start using more predictive modeling tools to shut down fraudsters before they begin receiving reimbursement, Sebelius and Holder announced. The Centers for Medicare & Medicaid Services has issued a solicitation for "state-of-the-art fraud fighting analytic tools to help the agency predict and prevent potentially wasteful, abusive or fraudulent payments before they occur."

The new predictive modeling tools will be used in conjunction with the Health Care Fraud Prevention and Enforcement Action Team (HEAT).

"By using new predictive modeling analytic tools we are better able to expand our efforts to save the millions -- and possibly billions -- of dollars wasted on waste, fraud and abuse," CMS Administrator Donald Berwick says in the release. Companies like banks, credit cards, and insurance use such programs already.

CMS also plans to use analytical software to spot real-time aberrant billing and fraudulent patterns, the release says.