Frank A. Rubino , ESQ.

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Health Care Act Empowers Smarter Medicare Fraud Investigations

According to some estimates, fraudulent healthcare claims account for nearly 10 percent of Medicaid and Medicare spending every year. New provisions in the Affordable Care Act arm government investigators with smarter enforcement tools to help them combat Medicare fraud.

The statute provides enough funding for investigators to begin using more sophisticated computer software. Much like the software that warns credit card companies of potentially fraudulent purchases, this new approach scans healthcare claims for unusual or suspicious patterns.

For example, the system can detect claims from two doctors in different states for treating the same patient on the same day.

Because the government receives around 4 million Medicare claims every day, the new fraud detection programs must be strong enough to process and analyze an enormous amount of information.

Traditionally, the government's enforcement approach followed a "pay and chase" model in which Medicare pays a claim first and investigates any suspicions second. The new software might enable Medicare to spot fraudulent claims before paying anything.

Investigators plan to begin targeting Medicare claims first but will eventually expand the program's focus to Medicaid fraud as well.

This new funding push represents another step in the government's increasingly aggressive acceleration of anti-health care fraud efforts. The Obama administration rapidly intensified enforcements since 2009, quadrupling the number of investigation teams.

As investigations intensify, prosecutions for health care fraud will also increase.

Source: NPR Morning Edition, "Health Law Gives Medicare Fraud Fighters New Weapons," Sarah Varney, Aug. 21, 2012

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