U.S. Attorney General Eric Holder and Health Secretary Kathleen Sebelius are set to meet at Philadelphia’s University of the Sciences today to discuss ways to combat health care fraud.
Health officials and law enforcement experts are ramping up for 2014. That’s when millions more Americans will have access to public health insurance. Mark Anderson leads New Jersey’s Medicaid Fraud Division. He says increased volume, means more opportunities for criminals to bilk the system.
“Making sure that taxpayers shouldn’t be paying for services for folks that don’t need it, or paying providers who aren’t providing the service, becomes as equally important as ensuring that the most vulnerable populations get served,” Anderson said.
Health care cheats drive up health costs, so New Jersey’s fraud unit is expanding. Anderson says he now has enough investigators to audit the state’s durable medical equipment suppliers. Those companies provide wheelchairs, adult diapers, orthopedic shoes and other supplies to patients. Experts nationwide say they’ve noticed abuses across the industry. “There’s a lot of different areas that we can look at to see if that DME provider is clean, to make sure that they are actually billing what they say, that they are providing the service that they say, that they are not overbilling the state,” Anderson said. Douglas Falduto is director of Corporate Investigations at Horizon Blue Cross Blue Shield of New Jersey. His fraud unit includes data miners who look for suspicious billing patterns. Horizon also relies on tips from vigilant customers. “A typical call would be: ‘I don’t recall having that service, I don’t recall having a surgical procedure, or I was never there that day,'” he said. Falduto says insurance companies now get more support from federal officials.
“Having the possible threat of actually doing prison time for this type of white collar crime is a huge improvement over where we were,” he said. Nick DiGiulio leads fraud investigations in Philadelphia for the U.S. Department of Health and Human Services. His group is tracking doctors who write painkiller prescriptions for cash. “They bill our public health insurance programs, Medicaid and Medicare. Drugs get into the hands of fraudsters, criminals who sell this stuff on the street, and these drugs provide the same high as the other illicit drugs that you normally see on the street, such as cocaine,” DiGiulio said. An agent in Philadelphia’s FBI office said ambulance fraud and staged car accidents are persistent problems in Southeast Pennsylvania.
U.S. Office of Inspector General – Fraud Hotline
Horizon Blue Cross Blue Shield of New Jersey – Anti-fraud hotline 1-800-624-2048