The Affordable Care Act’s War on Fraud

In April 2012, Kathleen Sebelius was in a triumphant mood.

“We have a simple message to criminals thinking about committing Medicare fraud: don’t even try,” the Health and Human Services secretary said in a news release. Sebelius went on to report that a record $4.1 billion in fraudulent Medicare billings had been recovered thanks to the federal Health Care Fraud Prevention and Enforcement Action Team (HEAT) and the Affordable Care Act (ACA).

The picture is not so sunny now for Secretary Sebelius or the ACA, but lost in the furor over ACA website problems is how Obamacare has already dramatically changed the way the government investigates Medicare fraud. That could have a big impact on providers and patients.

Medicare fraud prevention efforts have gone high-tech. The Centers for Medicare & Medicaid Services (CMS) is the agency that monitors data for signs of abuse. CMS now uses predictive modeling technology similar to that used by credit card companies to detect fraudulent transactions. The ACA earmarked $350 million to be spent on fraud prevention during the next 10 years.

Additionally, the government is now taking a closer look at health care professionals who apply for Medicare privileges in an attempt to keep fraud artists out of the system. The ACA specifically provides for increased provider screenings. If the Department of Health and Human Services has reason to believe an applicant poses a risk, the provider could be subjected to fingerprinting, criminal background checks and unannounced site visits.

The ACA also imposes tougher disclosure requirements on providers applying for or renewing Medicare privileges. If you have been affiliated with another provider or supplier who has had their billing privileges revoked, you must disclose that on your application. If the government believes your previous affiliation with a Medicare abuser makes you a high risk, your application could be denied. You do, however, have a right to appeal this decision.

If you are concerned about how the Affordable Care Act’s new anti-fraud provisions could affect your practice, consult an experienced New Jersey health care regulatory compliance attorney.

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Posted in: Healthcare Criminal Defense, Regulation