Medicare Fraud Steals $60 Billion a Year

Six months after a provider performs a particular medical procedure, they can bill it again. And, exactly six months to the day, the provider photocopies the original claim, changes the date, and sends the scammed claim it off to Medicare.

$60 billion worth of fraud is roughly 10% of the total amount Medicare pays out every year on healthcare for 54 million people. According to a March 7 WIRED article, "Since 2007 more than 2,300 providers have been charged with fleecing Medicare, and more than 1800 defendants have been convicted of felony offences, ranging from claiming phantom services to performing unnecessary surgeries."

Among CarePrecise Clients are the Federal Bureau of Investigation and state anti-fraud law enforcement bodies. CarePrecise provides comprehensive data on healthcare providers.

How will ever stop these scams? There are just too many of them for CMS' dedicated investigators to keep up. But the government is getting help from hundreds of citizens: whistle-blower lawsuits allow any medical office staff or other insider to sue their employer and collect 15% to 30% of the settlement. The number of bounty hunters is growing; in 2014 there were 469 such settlements resulting in $2.2 billion in fines.

Professional whistle-blower lawyers can help skittish employees to rat correctly, but they may not have the investigative chops. Now one clever business has begun to turn medical office whistle-blowing into a growth industry. National Healthcare Analysis Group may do more to help recover this money than has been possible in the past by organizing the process and "packaging" it. Read more about it...

Out of the Silos: Combined Healthcare Provider Data

You always knew it was possible to get all of the rich federal data on healthcare providers together in one place, and in a form you could use on your PC. And you were simply ecstatic when CMS released the NPPES database! But then you downloaded it and learned that there is simply no normal desktop software that can make that data accessible to you. Rats!

Then CarePrecise created a version of that data -- our flagship product, CarePrecise Access Complete (CPAC), so you could use all 4 million provider records on your computer. Yay! But then you found that it was hard to get around in all that data. Rats! So CarePrecise released the CP ListMaker software that makes getting at the data you want a walk in the park. Excellent! And you wanted some way to know which providers were sanctioned, or that they were eligible to bill Medicare, so CarePrecise integrated data from the PECOS (Medicare) database and the LEIE (List of Excluded Individuals and Entities). Fantastic!

Then you wanted more than the single practice location and fuzzy practice group data that the NPPES gave you, so CarePrecise integrated all of the Physician Compare data with CPAC. Cool! And you wondered how would you ever tame all of that hospital data, so CarePrecise integrated a de-duplicated list of hospitals and the Hospital Compare data, and while we were at it, we included hooks into the hospital quality data and the upcoming physician quality data. And all of it -- the NPPES, PECOS, LEIE, Physician Compare, Hospital Compare (plus some really nice additional stuff like proper-cased name and address fields, provider service area wealth data, and urban/rural/suburban designations) -- all integrated into a single relational database, linked by the NPI number. And you though it couldn't be done.

Now we call that sweet package of data heaven by a weird name: The CarePrecise Total Bundle. And as we integrate upcoming federal data releases, will we be tucking them in there too? You betcha. That's what CarePrecise is all about: healthcare provider data integration and application.

It's brand new and available now: The only 360 degree view of U.S. healthcare provider data. Total Bundle pricing is just $689. That's less than 2/100ths of a penny per record for the most complete physician database / hospital database / dentist database... available anywhere.

You're welcome!

Healthcare Fraud Recovery $4.2B for 2012

Attorney General Eric Holder and HHS Secretary Kathleen Sebelius released a report today indicating that for every $1 spent on healthcare fraud and abuse recovery, $7.90 has been returned to the treasury over the past three years. With the Obama administration making recovery a top priority, this is the highest level of return in the 16-year history of the program.

Health Care Fraud Prevention and Enforcement Action Team (HEAT) was created in 2009 to reduce fraud, waste and abuse in the Medicare and Medicaid programs and to crack down on individuals and organizations that are bleeding the system. Last year, the Justice Department opened 1,131 new criminal fraud investigations involving as many as 2,148 defendants. Convictions have been achieved on 826 defendants in fraud-related crimes during the year. In the same year, the department opened 885 new civil investigations.

In 2012, CMS began screening all 1.5 million Medicare-enrolled providers through the new Automated Provider Screening system. APS fingers ineligible and potentially fraudulent providers and suppliers prior to enrollment or revalidation. Nearly 150,000 ineligible providers have been eliminated from Medicare’s billing system so far. 

CarePrecise's standard database of healthcare providers includes a field that indicates providers who may still be active, but have been added to the federal List of Excluded Individuals and Entities, tying excluded providers to their NPI numbers.

The Sunshine List

As lawmakers continue to push CMS to implement the Physician Payments Sunshine Act, and CMS mildly demurs out of concern that drug and equipment manufacturers won't be able to comply any time soon, CarePrecise has been busy getting prepared for a run on the databank.

As most of the players are beginning to realize, an accurate and up-to-date source of provider information will be a necessity in reporting payments properly. The CarePrecise master provider list contains all the hooks required to positively identify specific providers, and connects provider licensing and NPI numbers to such pertinent information as PECOS enrollment, Medicare billing eligibility, and the Office of Inspector General's excluded providers database. The current version of the CarePrecise Access Complete database identifies multiple providers practicing at a single location, using super-conformed location coding.

Sunshine Incoming

CarePrecise can process incoming lists of payments to providers using the advanced record-linking technology we use to build our master databases. Whether companies have NPI numbers or not, our system can use other data to identify payees.

CarePrecise data is already in use is installations where states have various types of Sunshine laws in place, and where organizations are preparing for the federal act to take effect. When we can all finally see who's paying what to whom (to whatever extent that will be truly possible), CarePrecise data will be part of this vital next step in controlling healthcare costs and abuses of influence.

91 Charged With $295 Million Medicare Fraud

Ninety-one doctors, nurses and others were charged in a blockbuster sting operation, with arrests unfolding over three weeks and culminating in 70 arrests last week. In 2007, a strike force was set up between the Department of Justice and the Department of Health and Human Services to identify and build federal fraud cases to fight criminal abuse of federal healthcare programs. U.S. Attorney General Eric Holder said that arrests were made in eight US cities involving more than $295 million in stolen funds.

Almost half of those charged were part of a Florida ring that recruited healthcare providers to refer patients to a mental health center, in some cases threatening residents of a halfway house with eviction if they refused the unnecessary care. Another case involved $3.4 million in unnecessary physical therapy by two Brooklyn physicians.

On September 1, officials in Detroit charged 18 physicians, nurses, clinic owners and other medical professionals for submitting $28 million in false claims to Medicare. Just one day earlier, the owner of a Houston, Texas durable medical equipment business was sentenced to 97 months in prison for his role in a Medicare fraud scheme.

In all, the strike force, known as Health Care Fraud Prevention and Enforcement Action Team (HEAT), has charged 1,140 defendants who collectively have falsely billed the Medicare program for more than $2.9 billion.

When providers have been convicted of fraud and certain other infractions and delinquencies, their names are placed on the List of Excluded Individuals/Entities (LEIE) database. CarePrecise compiles this data into its comprehensive database of U.S. healthcare providers, identifying excluded providers' NPI numbers, phone and fax numbers.

Read the full story on the HHS website.

A Nut Too Tough to Crack?

One of the hardest problems in health IT is the effort to get data from different silos into a centralized database that can be searched as a single dataset. So, this is us announcing our new "linking and shrinking" technology, code named "Squirrel." What does it do?

Squirrel is a record-linkage and deflation system that pulls in data from multiple federal provider databases in various formats, makes them play nice together by linking everything up under providers' NPI numbers, preserves all the data but shrinks the file size down to about 9% of the original size, puts it in a format that can be managed in Microsoft Access or other garden variety database software, downloads it to our customers, and then does it all again fresh every month.

The technology is built on record-linkage methods developed over twenty years. Interesting trivia: The precursor to the current system was built in Microsoft Access 1.0 -- you remember it, the Introductory Package -- in 1992. While we don't share all the secrets, the basic trick involves pattern matching algorithms and a lot of processing time to handle more than 13 million rows of data, comparing each provider's records between all the sources. The end result is called CarePrecise Access.

We just sent out a press release about the whole thing.

Now you'll excuse us, as we have some more nuts to collect and crunch on.