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Eliminating Medicare fraud and enhancing analytics

Matthew H. Berls (matthew_h_berls@uhc.com) is Senior Director of Investigations and Richard E. Munson (rick_e_munson@uch.com) is Program Integrity Chief Compliance Officer & Vice President, Investigations at UnitedHealthcare in Minnetonka, MN.

The Protecting and Improving Medicare for Our Nation’s Seniors executive order,[1] issued October 3, 2019, addressed two areas that may be of interest to Health Care Compliance Association members. The first is section eight: Empowering Patients, Caregivers, and Health Providers; and the second is section nine: Eliminating Waste, Fraud, and Abuse to Protect Beneficiaries and Taxpayers.

Healthcare fraud is a systemic issue victimizing millions of Americans, and it demands greater attention. “The National Health Care Anti-Fraud Association (NHCAA) conservatively estimates that 3%–5% of the nation’s total spending on healthcare is lost to fraud.”[2] The National Center for Health Statistics, housed within the Centers for Disease Control and Prevention (CDC), calculates that healthcare expenditures in America total $3.5 trillion.[3] If we were to apply NHCAA’s 3%–5% range, fraud is, conservatively, claiming $99–$165 billion of our nation’s healthcare expenditures. Sadly, if one was to include fraud, waste, and abuse (FWA), the percentage would be closer to 10%.

Even with $99–$165 billion at stake, preventing, detecting, and correcting healthcare FWA is a topic routinely underpublicized, unappreciated, or given negative attention. There is an unfounded belief that private insurers and law enforcement agencies aren’t doing enough to combat healthcare FWA. As a response, here is a quote from God in the “Godfellas” episode of Futurama, “When you do things right, people won’t be sure you’ve done anything at all.”

Special Investigations Units within private insurers collaborate with state and federal regulators, law enforcement agencies, professional associations, and licensing authorities to combat FWA. This group is commonly referred to as public and private partners. With that said, let’s look at the executive order and the effects it may have over the next year and beyond.

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