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. 

Medicare Part D still vulnerable

Despite the impressive fraud recovery dollars, a few areas remained in the spotlight throughout 2014. One was Medicare Part D, which has been a longstanding fraud hotspot (.pdf). In March, the Office of Inspector General (OIG) offered a friendly reminder to CMS that it's still not very good at uncovering Part D fraud--probably because CMS does not require fraud and abuse reporting but, instead, encourages Part D sponsors to report potential fraud. As a result, just 54 percent of sponsors didn't report at all. A couple months later, CMS released new rules to screen drug prescribers, release more Part D data, and collect information directly entities that contract with sponsors.

Of course, this didn't stem the tide of Part D problems that trickled in throughout the year. In August, the OIG noted that Part D spent $32 million on HIV drugs for people who may not have needed them; more than one-third of them hailed from Miami or New York. A month later, OIG singled out pharmaceutical companies for not doing enough to stop coupons from being used for Part D drugs; this practice can put them on the hook for violating anti-kickback statutes.

Finally, fraud involving controlled substances continued throughout the year as forged prescription schemes and unlawful distribution of narcotics such as Oxycodone made headlines. Fraud schemes continued to flourish under the Part D program, with narcotic painkiller prescriptions for Medicare patients spiking nine percent and 12 of the top 20 prescribers in the program showing signs of a troublesome past.

Home is where the fraud is

If there was any doubt that home health was a problem area for fraud, a slew of stories from 2014 wiped it out. FierceHealthPayer: AntiFraud's exclusive interview with Haynes and Boone's Sean McKenna revealed that home healthcare was on the law enforcement and payer radar, and throughout the year that proved true.

In June, the Center for Public Integrity published a report looking at the potential for fraud in house calls, and a subsequent investigation found that Medicare spending for home-visit services skyrocketed. Meanwhile, Michigan's Medicaid Home Help Program was found to have overpaid $160 million in 29 months as a result of sloppy paperwork and improper monitoring.

The month of December offered no shortage of home health fraud cases throughout the country, leaving the distinct impression that this problem will likely trickle into 2015 and beyond.

Data analytics is the future--unless you're in Texas

Fraud experts repeatedly pointed towards data analytics and informatics as the wave of the future for fraud prevention, offering an opportunity to move past the antiquated "pay-and-chase" model into an age where payment data would provide preemptive fraud detection. In an effort to support that vision, in November CMS announced that it would create an office of enterprise data and analytics that would let the government use predictive analytics to identify fraud and abuse. Meanwhile, states such as Indiana and North Carolina used data analytics to thwart fraud, saving $85 million and $33 million, respectively.

Of course, it wasn't all good news, as Texas offered up its nomination as the "Goat of the Year" when an investigation revealed Texas botched a $110 million contract with a software company that was hired to detect fraud. The months-long disaster eventually cost two Texas Health and Human Services Commission administrators their jobs.

There you have it: The good, the bad, and the ugly of healthcare fraud in 2014. But don't wipe the slate completely clean; many of the fraud trends seen over the past year are likely to carry over into 2015.