Reviewing the year in healthcare fraud
Many of us use the 24-hour transition from New Year's Eve to New Year's Day to reflect on the previous year, mulling over the good, the bad and the ugly of the previous 12 months. And if there's more "bad" or "ugly" than "good," you can always just forget the whole ordeal and start fresh.
There's no question that fraud prevention and detection have taken on a larger role as the federal government has put increasingly more resources toward recovering money from false claims and fraudulent billing activity. But 2014 may have been the most significant thus far, seeing as it began and ended with record-breaking fraud and false claims recoveries, with an inaugural Centers for Medicare & Medicaid Services (CMS) data dump sandwiched in between.
As we settle into the New Year, let's take a brief look at some of the most important stories of 2014 and the impact they had.
Yes, the government cares about fraud
In case you remained unsure about the feelings the federal government has towards fraud identification and recovery, consider the increased funding that President Barack Obama devoted to fraud enforcement for fiscal year 2015. Despite a $1.3 billion reduction in the Department of Health and Human Services (HHS) budget, the president injected $403 million into the Health Care Fraud and Abuse Control program, along with a $105 increase in funding for the HHS Office of Inspector General.
By the end of the year, CMS had released a new final rule aimed at booting "bad actors" from the program, a rule that offers the agency greater discretion to justify refusing or revoking enrollment.
CMS payment data makes a big splash
The Obama administration hailed the inaugural release of CMS physician payment data as move that would "make our healthcare system more transparent," and articles vaguely referenced "consumer groups and news outlets," but the true credit goes to the Wall Street Journal, which prevailed in a lawsuit to eliminate a 1979 injunction that prevented the disclosure of annual Medicare reimbursement amounts.
The data dump made headlines for weeks as news outlets combed through data showing a small number of physicians getting a large portion of Medicare reimbursement. It certainly provided plenty of fodder for fraud investigators, and lawyers predicted increased litigation as a result. Soon after, two doctors whose combined earnings totaled nearly $30 million were accused of overbilling and fraud. Other physicians made millions even though they had been thrown out of Medicaid, indicted or charged with fraud, or settled false claims allegations.
It was a polarizing topic as well. The Ameican Medical Association argued that data without context would lead to inaccuracies and false conclusions. Susan Turney, M.D., president and CEO of the Medical Group Management Association (MGMA) told FierceHealthcare that the data would be "detrimental to patients and providers" without proper context in place.