The United States currently spends $2.7 trillion on health care each year, generating billions of claims in the private and public health systems. With the estimates for fraud and abuse in our health care system ranging from 3 to 10 percent of expenditures, this translates into financial losses due to fraud and abuse in the tens of billions of dollars each year.
Those losses impact both public payers, such as Medicaid and Medicare, and private sector health insurance plans, as well as health care providers and taxpayers. Fraud and abuse also harms patients in the form of unnecessary services being provided solely for the purposes of filing false claims, or from the diversion and misuse of prescription drugs. In some instances, patients have died from unnecessary treatments, and many more have died from overdoses of diverted prescription narcotics. And, of course, many individuals also spend hours repairing the damage that results from medical identity theft. While there is no silver bullet for stopping health care fraud, there is an initiative underway aimed at helping to tackle this complex problem: the Health Care Fraud Prevention Partnership (HFPP).
The HFPP is a voluntary, public-private partnership among the Federal government, State officials, private health insurance plans, and anti-fraud associations, including NHCAA. It was created to improve the capabilities to detect and prevent health care fraud across both private and public payers. To date, over 30 partner organizations have joined, and it is expected that additional partners will be invited to participate in 2014.
NHCAA strongly supports the partnership and its goals. Our association has been dedicated to helping the private and public sectors come together to fight health care fraud for nearly 30 years. We know that anti-fraud information sharing between the private and public sectors, along with education and training, are the keys to effectively meet the challenge of health care fraud. Here at NHCAA we accomplish this through a number of channels, including our SIRIS database, hosted by LexisNexis, in-person meetings, conferences, webinars and research. The HFPP, however, enables the health care community to build on NHCAA’s work, as well as the best practices of the partnership’s members.
The partnership’s emphasis is on cooperation and exchanging data and information across the public and private sector partners. Here’s why: each payer only has access to its claims data to detect fraud and abuse. All it can see is its data. However, hospitals, group medical practices and providers bill many payers, usually including several private insurers, Medicare and Medicaid. When an insurer is trying to understand the scope of the health care fraud problem, all it is seeing is one piece of the problem. The payer isn’t seeing all the claims the provider may be generating with other insurers or public health programs.
The goal of the HFPP is to exchange data and information across the private and public sector partners for targeted anti-fraud studies, leveraging analytical tools against integrated data sets provided by the partners for study results. The partnership also will provide a voluntary forum for business and government leaders and subject matter experts to collaborate and share successful anti-fraud practices and effective methodologies and strategies for detecting and preventing health care fraud. The focus will be on data sharing and analytics along with outreach and information sharing.
At NHCAA, we are excited about this partnership. It demonstrates a strong government commitment to work with the private sector on fraud prevention. It also shows that the government, like the private sector, is trying to get ahead of those perpetrating fraud by shifting its focus away from the “pay and chase” approach to one focused on early fraud prevention and detection.
We know that the old way of fighting fraud, where public and private payers stay narrowly focused on their individual datasets, isn’t the most effective strategy. Doing so only provides a narrow snapshot of the fraud; what is needed to combat the full scope of the problem is a broader view of how it is happening. That’s what the HFPP is committed to doing. But, it is only as strong as its partners and their participation. So, my message to the health care marketplace is this: look for opportunities to partner with other organizations on anti-fraud initiatives, participate in NHCAA, and, as the HFPP is able to expand in the coming year, actively participate. Together, we can meet the challenge and have a significant impact in preventing health care fraud.