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David McGill Blogger

Public-Private Cooperation Spells Higher Risk for Providers

Posted by David McGill | August 02, 2012

On July 26, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder announced a new partnership between the federal government, State officials, and key private insurers to identify and prevent health care fraud. In announcing the new initiative, Holder stated that “[b]ringing additional health care industry leaders and experts into this work will allow us to act more quickly and effectively in identifying and stopping fraud schemes, seeking justice for victims, and safeguarding our health care system.”

Among the organizations participating in this effort are:

  • America’s Health Insurance Plans
  • Amerigroup Corporation
  • Blue Cross and Blue Shield Association
  • Blue Cross and Blue Shield of Louisiana
  • Centers for Medicare & Medicaid Services
  • Coalition Against Insurance Fraud
  • Federal Bureau of Investigations
  • Health and Human Services Office of Inspector General
  • Humana Inc
  • Independence Blue Cross
  • National Association of Insurance Commissioners
  • National Association of Medicaid Fraud Control Units
  • National Health Care Anti-Fraud Association
  • National Insurance Crime Bureau
  • New York Office of Medicaid Inspector General
  • Travelers
  • Tufts Health Plan
  • UnitedHealth Group
  • U.S. Department of Health and Human Services
  • U.S. Department of Justice
  • WellPoint, Inc.

What is the significance of this announcement? While the impact of this new partnership probably won’t be felt until 2013 at the earliest, it suggests that the environment of increased audits, prepayment reviews, and overall enhanced scrutiny of claims that we’ve seen in the Medicare program over the last 12 months is not only unlikely to slow down, but will instead expand into the private payer marketplace as well.

If that is the case, having detailed and complete medical records, coordinating and collaborating with physicians, and being able to demonstrate that your care and treatment leads to objectively verifiable positive outcomes will be the key ingredients to running a successful O&P business in the long term. We therefore recommend that you take time before the end of this year to perform a comprehensive, objective review of your record-keeping and billing practices. Identify your areas of weakness and fix them now. The time and money you spend today on those efforts may be the difference between you succeeding and failing tomorrow.

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