Healthcare has entered the era of “Compliance 2.0,” fueled by information technology and analytics designed to root out fraud, contends Daniel Levinson, Inspector General of the Department of Health and Human Services.
Levinson, who has headed the HHS OIG for more than a decade, made the remarks in a keynote address at last week’s Health Care Compliance Association conference.
“We’re really looking at a different era,” which is bringing “together technology with the right expertise,” said Levinson during the 2017 HCCA Compliance Institute. “When we got off the ground in the mid-1990s, it was really the beginning of the Internet age. A lot has happened in 20 years technologically. Now, we have the kinds of tools that we couldn’t have imagined 20 years ago.”
For its part, OIG’s mission is to protect the integrity of HHS programs and operations, by detecting and preventing fraud, waste and abuse. According to Levinson, IT is playing an enabling role bolstering fraud detection and prevention.
“On the healthcare fraud side, we’re working very productively with the Healthcare Fraud Prevention Partnership, with private payers and us at the table,” added Levinson.
Created in 2012, HFPP is a voluntary public-private partnership advancing the detection and prevention of healthcare fraud, waste and abuse by sharing data industry-wide and collaborating on effective methodologies. HFPP is the only organization through which partners can combine their data with that from the Centers for Medicare and Medicaid Services to gain anti-fraud insights using enhanced analytics.
“We’re really able to share important information about risk areas and about the kinds of things we see both on the private and the public side. So, we’re able to catch various schemes much earlier than we had been able to in years past,” added Levinson.
He noted that home health services is a growing area of healthcare that requires more attention and focus for fraud detection. Levinson referenced the recent Texas case of Jacques Roy, MD, who orchestrated a massive Medicare fraud scheme by submitting $375 million worth of bills for bogus home health services.
“Home health is now such a large part of what we see—we spend probably $18 billion to $19 billion at HHS on home health agencies for 11,000 different providers,” Levinson concluded. “There are serious vulnerabilities when it comes to home health because it is more difficult to track.”
At the same time, he said Medicaid program integrity “remains a very significant challenge because as we move more towards managed care—from the standpoint of us as auditors and evaluators—we see a system that is much more opaque than really suits our ability to assure that taxpayer dollars are being used appropriately.” Regulators want to know who HHS is “doing business with” and “providers are qualified,” and the “money is going to people who deserve those fees.”
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