Healthcare fraud and abuse pose significant challenges to the healthcare industry and the overall healthcare system. Efforts to combat fraud and abuse have been consolidated and strengthened under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and subsequent initiatives.
HIPAA and the Health Care Fraud and Abuse Control Program (HCFAC)
HIPAA established a comprehensive program to combat fraud committed against health plans, both public and private. It mandated the establishment of a national Health Care Fraud and Abuse Control Program (HCFAC), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS) acting through the Department’s Inspector General (HHS/OIG) .
The HCFAC program is designed to coordinate federal, state, and local law enforcement activities with respect to health care fraud and abuse .
Magnitude of the Problem
Medicare fraud alone has been the cause of up to $60 billion in overpaid claims in 2015 .
Fraud or abuse by managed care plans can further increase Medicaid costs .
Prevention and Detection
Efforts to prevent, detect, and report Medicare fraud and abuse are crucial. Trust is core to the physician-patient relationship, and Medicare and other Federal health care programs rely on trust in physicians .
Challenges in Fraud Control
The complexity of the fraud control challenge is seriously underestimated by the health care industry. Existing control systems are not targeted on criminal fraud and cannot be expected to control it .
Solutions to Mitigate Fraud and Abuse
A multi-layered strategy to address program integrity issues that emphasizes education and employers’ implementation of front-end analytics to mitigate fraud and abuse at the practice site has been proposed .
Awareness and Education
Healthcare anti-fraud associations seek to identify and reduce fraud and abuse in the area of clinical laboratory services, highlighting the importance of awareness and education in combating healthcare fraud and abuse .
Public Awareness
It’s important for individuals to be aware of healthcare fraud, waste, and abuse, as it affects everyone in the U.S. .