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Seven predictions for the future of healthcare fraud enforcement


Over the course of a year, it's easy to lose sight of the big picture. Usually we're so focused on day-to-day tasks and responsibilities, we don't have the time or patience to think about anything more than what's right in front of us.

The end of the year offers an opportunity to catch our collective breath. If anything, it's a simple and effective demarcation--the end of one year and the beginning of another--that allows for a moment of reflection.

For me, the new year offers a chance to look back at the healthcare fraud stories I've covered over the last 12 months. That's when the bigger picture begins to take shape as enforcement trends and fraud concerns emerge with a year worth of stories lined up next to one another.

Read the fine print: I'm not a licensed fortune teller. If I was, I would have guessed the winning lotto numbers a long time ago. More often than not, predictions are an exercise in futility. But they're also fun, so here are my seven predictions for healthcare fraud in 2016.

Hackers will be the next great avenue for healthcare fraud.

Prior to 2015, the largest healthcare data breach was a 2014 hack that exposed the personal information of 4.5 million at Tennessee-based Community Health Systems. Then the Anthem hack happened, compromising information for 80 million people, including the company's CEO.

It was a bit of a wake-up call. If it can happen to the second-largest insurer in the country, it can happen to anyone. From a fraud perspective, it had longstanding consequences that opened up multiple avenues for schemes using stolen information.  

Since that Anthem hack, other healthcare providers and insurers have reported breaches of their own, including one against Healthfirst that was traced back to a criminal fraud scheme. Considering health information is worth 10-20 times more than credit card information (because it can be used to effectuate much more lucrative schemes) it's easy to see how hackers will play a larger role in the fraud landscape.   

The feds will be forced to confront the Medicare Advantage elephant in the room.

The looming concerns surrounding Medicare Advantage risk scores have been building steam for more than a year, and now it seems close to exploding thanks to a lot of grunt work from the Center for Public Integrity (CPI). In February, the Department of Justice (DOJ) requested information from Humana about Medicare Advantage risk scores. By April, six whistleblower lawsuits had been filed citing inflated risk scores, and even more lawsuits were in the pipeline by August, implicating as many as 30 insurers.

Secret government audits exposed over the summer hinted at millions in potential overpayments. Just last month, CPI released another report that showed the Centers for Medicare & Medicaid Services (CMS) held back on auditing Medicare Advantage plans despite finding overpayments as high as $7 billion in 2008.

Senators on both sides of the aisle are getting restless, and this problem is getting too big and too messy to ignore. I wouldn't be surprised to see one or more of these whistleblower suits make more headway in the coming year, perhaps with some government assistance.