Payers must combine resources to red flag fraudulent claims

May 1, 2011

Healthcare fraud costs Americans between 3% and 10% of each dollar spent.

Key Points

A white paper from The National Health Care Anti-Fraud Assn. (NHCAA), "Combating Health Care Fraud in a Post-Reform World: Seven Guiding Principles for Policymakers," outlines proposals the group believes will curb the problem. Of particular interest is the idea that anti-fraud information should be passed freely among private and public insurers and that health plans should have more leeway to bar providers suspected of fraud.

NHCAA's Special Investigation Resource and Intelligence System (SIRIS) database, where health plans can report fraudulent providers, has been underutilized because of a reluctance to input the data, says Barry Johnson, president of HealthCare Insight, which provides payment integrity solutions.

Participating Blue Cross Blue Shield companies have collaborated on Blue Health Intelligence, which allows mining of claims data to uncover trends, including those regarding fraud and abuse.

T. Markus Funk, who leads the investigations and white collar defense group at Perkins Coie, believes the healthcare industry needs a common database, much like the information-sharing partnership between the Federal Bureau of Investigation and the private sector tracking cyberterrorism.

"Fraud schemes don't discriminate between public and private troughs of money," says Funk, who prosecuted a number of healthcare fraud cases while serving as an assistant U.S. attorney. "A highly fortified private/public partnership could help staunch the redistribution of wealth from law-abiding citizens to the criminal class."

Funk acknowledges that private plans likely are reluctant to share information due to concerns about patient confidentiality and proprietary data, but he says those concerns are groundless.

Funk says. "It's a false dichotomy to think you have to throw your books open," he says.