Anti-fraud collaborative efforts

Alam Singh III Workshop on HI fraud

Overview of industry & government initiatives

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Agenda

Overview of anti-fraud initiatives in health insurance

– US

– Other markets

Niche initiatives

Auto insurance initiatives

Key learnings

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Overview of major industry initiatives in US

USD 2 trillion healthcare expenditure annually in US, fraud estimated vary, reasonable estimate at USD 6-8% or USD 120 – 160 billion.

National Health Care Anti-Fraud Association (NHCAA): A public – private partnership founded in 1985, 150+ private health insurers and federal and state government members and 500 individuals. Goals: education & training, collaboration, dialogue.

Coalition Against Insurance Fraud: a coalition of insurance organizations, consumers, government agencies and legislative bodies formed in 1993. Promotes anti-fraud legislation and public education (ie: scam warnings, how to report fraud, and how to protect themselves).

The Patient Protection and Affordable Care Act, 2010, includes new anti-fraud and abuse provisions, strengthens the federal False Claims Act (e.g., by allowing broader sources of information to bring a whistleblower suit) and the Anti-Kickback Statute. New requirements regarding return of overpayments, additional federal funding and enforcement powers to fight fraud and abuse, and increased criminal and civil penalties.

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Overview of major government initiatives in US

Primarily focus on Medicare and Medicaid fraud. HIPPA ‘96 included provision for creating a Health Care Fraud and Abuse control program (HCFAC). Multi-prong program with RoI focus, since inception about USD 4.9 recovered for 1 spent, latest 3 year average USD 6.8. Initiatives include StopMedicareFraud.gov, HEAT teams & whistleblower program. :

Health Care Fraud Prevention and Enforcement Action Team (HEAT): Medicare Fraud Strike Force, includes federal, state and local investigators. Based in fraud prone areas and currently managing 2400 concurrent investigations. Can conduct highly sophisticated investigations and frequently focus on scams conducted by organized crime, ie:

115 people, 9 cities, USD 240 million in false billings 91 people, 8 cities, USD 290 million in false billing

Dedicated prosecution teams and strong sentencing guidelines: Conspiracy to commit health care fraud, maximum 10 years / $250,000 fine. Submission of false claims to the Medicare, maximum five years. (example)

Medicare & Medicaid Fraud Reporting Center: offers whistleblower rewards that allow healthcare professionals to collect upto 30% of the fines government collects, sometimes can be millions of dollars.

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Major industry initiatives, other marketsMixed healthcare systems in Canada, EU & UK, public delivery to government run insurance program and private insurance. Thus a broader focus on “healthcare” fraud.

The Canadian Health Care Anti-fraud Association (CHCAA): Founded in 2000, goals are to educate and create awareness, build public - private partnerships with law enforcement, health regulatory bodies, consumer groups, and provider associations.

The European Healthcare Fraud & Corruption Network (EHFCN): Established in 2005, pan European network represents 25 member associations in 15 countries, EHFCN provides information, tools, training and assistance in fighting fraud.

The Health Insurance Counter Fraud Group UK (HICFG): membership consists of health insurance companies and is supported by the Association of British Insurers and NHS Counter Fraud.

NHS Counter Fraud (UK): 300+ counter fraud specialists in the NHS, providing oversight to a GBP 100 billion budget.

All of the above are members of Global Health Care Anti-Fraud Network (GHCAN). Working cooperatively to improve international standards of practice around fraud prevention.

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Overview of niche initiatives International Association of Special Investigations Units (IASIU): founded in 1984,

non-profit organization to coordinate effort within the industry to combat insurance fraud and providing education and training for insurance investigators.

Pennsylvania Fraud Prevention Authority: a regional initiative, created by a state assembly act with sole purpose is to combat insurance fraud throughout the state. Funded by levy on all insurance companies. Commits approx. USD 10 million annually to 16 law enforcement agencies and USD 2 million each year in public education. Creates a quarterly newsletter which is case study based. (example)

National Insurance Crime Training Academy (NICTA): National Association of Independent Insurers (NAII) & National Insurance Crime Bureau (NICB) jointly with FBI Academy and the National White Collar Crime Center initiated this project. It is web based and trains insurance personnel and law enforcement officers to increase the deterrence, detection, investigation and prevention of fraudulent claims.

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Overview of auto insurance initiatives National Insurance Crime Bureau (NICB): Not for profit structure with a focus on auto

insurance, with 1,100 members (P&C insurers, rental and transportation related companies). Over 300+ employees. Famous for VINCheck.

Auto theft prevention authorities (ATPA): in USA, Canada & Australia, mostly organized at state level. Funded by contribution ranging from USD 1 – 10 per vehicle per year collected from owners by insurers. Goal is to foster partnerships amongst auto crime prevention organizations and agencies, access to information, coordinate a unified front in auto crime prevention. Identify local, state and national trends regarding auto crimes.

Insurance Institute for Highway Safety (IIHS) & The Highway Loss Data Institute (HLDI) & Insurance Research Council (IRC): all non-profit and supported by insurers.

IIHS is dedicated to reducing the losses from crashes on the nation's highways. HLDI studies data to present losses resulting from the ownership and operation of

different types of vehicles and by publishing insurance loss results by vehicle make and model.

IRC conducts public opinion surveys, analysis of insurance statistical experience, closed claims studies (on auto injuries) and simulation studies.

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Common attributesGoals

Measure & educate Deter & prevent Detect & investigate Prosecute / sanctions Recovery Create a real anti-fraud culture: within service providers, medical suppliers, payers, users and policy makers.

Methods

Educate to increase public awareness Sharing of good practices, development of common working standards Data analysis Providing information, tools, training and assistance Collaborate

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Questions?