The size of the prize makes it imperative that we do better—and with the proper technology, we can.
Dulles, VA (PRWEB) November 17, 2015
Scams against government and private healthcare insurers are the largest types of insurance fraud. While the exact amount of money stolen in this way is unknown, it’s estimated to be in the tens of billions; the National Health Care Anti-Fraud Association puts the total at close to $100 billion per year.1
“Whatever the actual total is,” says Susan Deehan, Chairwoman and CEO of Actionable Intelligence Technologies, the nation’s leading supplier of solutions for financial investigations, “it’s increasing rapidly.”
Per Deehan, the increase in fraud stems from the increase in the nation’s overall healthcare expenditures and fraudulent activity and the size of the annual U.S. healthcare budget, which is a magnet to criminal organizations. Figures from the Centers for Medicare & Medicaid Services show that healthcare expenditures in the U.S. will reach $3.2 trillion in 2015, or about $10,000 per person. In 2014, Medicare spending alone reached $616.8 billion.2
While healthcare fraud is a national issue, there appear to be certain hotspots. The Office of Inspector General released a report in 2012 on the efforts of federal/state Medical Fraud Control Units (MFCUs), which investigate and prosecute fraud, as well as patient abuse and neglect at healthcare facilities. In 2011, MFCUs conducted 10,685 Medicaid fraud investigations, resulting in 824 convictions. Of the convictions, 464 took place in only five states: California, Texas, New York, Ohio, and Kentucky.3
Other government anti-fraud initiatives are also working to apprehend fraudsters and recoup some of the money lost in wrongful payments. According to the Coalition Against Insurance Fraud, over $27.8 billion has been returned to the Medical Trust Fund since the Health Care Fraud and Abuse Program was created in 1997. The Medicare Strike Force was created in 2007, since then it has lodged 1,285 criminal actions and charged more than 2,300 defendants. The Department of Justice has recovered more than $15 billion in healthcare fraud cases over the past five years, and the average prison sentence for Medicare Strike Force cases in 2014 was more than four years. Some prosecutions in recent years have earned sentences up to 50 years.4
Additional tools are made available to fraud fighters by the Affordable Care Act, which provides $350 million over ten years to boost anti-fraud efforts and increases federal sentencing guidelines for health care fraud by 20-50 percent for crimes resulting in over $1 million in losses. In 2009, the fight against Medical fraud became a Cabinet-level priority with the creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), which reports to the Secretary of Health and Human Services and the Attorney General.5
Even with these efforts, there are still high rates of fraud in the industry, nearly $80 billion of improper Medicare and Medicaid payments were made in 2014. Of this amount, $60 billion involved improper Medicare payments, which is about 10 percent of the $603 billion spent to provide coverage for 54 million Medicare beneficiaries last year. The $60 billion figure is also the largest portion of the total of $124.7 billion in improper payments across all federal programs.6
In the U.S., recent evidence shows that an increased investment in fraud prevention would yield a significant return. The Healthcare Fraud Abuse and Control Program and its sister initiatives have returned $7.70 for every dollar invested since 1997. The Medicaid Fraud Control Units have performed even better; the office of Inspector General reports that ROI for their initiatives has amounted to $8.39 for every dollar invested.7
“It’s a straightforward business proposition,” says Deehan. “The size of the prize makes it imperative that we do better—and with the proper technology, we can. For example, the financial services industry considers 1 tenth of 1% to be an acceptable level of fraud risk/loss and the industry invests in the necessary resources to achieve that goal. This compares to the fraud estimates in health care industry of more than 10%, some experts think the actual rate of fraud may approach 20%.”
To help strengthen the ability of law enforcement agencies to combat white-collar crime, including healthcare fraud, AIT has developed a tool called the Comprehensive Financial Investigative Solution (CFIS), which allows an investigator to process and analyze financial records exponentially faster and more accurately than with manual methods. Investigators using CFIS technology can perform data entry and analysis in hours and days that would take months and years using conventional methods.
About Actionable Intelligence Technologies:
Headquartered in Dulles, VA, award-winning Actionable Intelligence Technologies is the nation’s leading supplier of solutions for financial investigations. AIT’s customers include the New York Attorney General’s Office, United States Attorney’s Office, the Criminal Division of the Internal Revenue Service, the United States Postal Inspection Service, Department of Securities, Securities and Exchange Commission, Federal Trade Commission, and other important state agencies, as well as the Miami Dade Police Department, United States Department of Agriculture, numerous commercial and international forensic accounting firms and many others. Founded in 1998 by Susan M. Deehan and Tim Deehan, AIT is dedicated to helping financial investigators make our country a safer place to live. AIT’s mission is to fight against financial crime by delivering the technology and expert knowledge to detect, investigate, and permanently dismantle the criminal organization. References available on request. For more information, visit http://aitcfis.com
1. National Health Care Anti-Fraud Association, “The Challenge of Health Care Fraud.” nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx
2. Centers for Medicare & Medicaid Services, “National Health Expenditure Projections,” July 30, 2015. cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html
3. Cheung-Larivee, Karen, “5 states top Medicaid fraud list, States recover $1.7B,” Fierce Healthcare. fiercehealthcare.com/story/5-states-top-medicaid-fraud-list-states-recover-17b/2012-04-03
4. “By the numbers: fraud statistics,” Coalition Against Insurance Fraud.
5. “The Affordable Care Act and Fighting Fraud,” U.S. Department of Health & Human Services and U.S. Department of Justice. stopmedicarefraud.gov/aboutfraud/aca-fraud/index.html
6. United States Government Accountability Office, “Testimony before the Committee on the Budget, U.S. Senate,” gao.gov/assets/670/668828.pdf
7. U.S. Department of Health and Human Services, “Departments of Justice and Health and Human Services announce over $27.8 billion in returns from joint efforts to combat health care fraud,” hhs.gov/about/news/2015/03/19/departments-of-justice-and-health-and-human-services-announce-over-27-point-8-billion-in-returns-from-joint-efforts-to-combat-health-care-fraud.html