How do investigators identify Medicare fraud?

On Behalf of | Sep 23, 2014 | Medicare and Medicaid Fraud

How do you think federal agencies and investigators ferret out instances of alleged fraud? Medicare fraud is a growing concern for investigators throughout the nation, including those in Florida. In recent years, the Centers for Medicare & Medicaid Services have implemented massive strategic initiatives designed to fight fraud in the system. Those initiatives include the identification of nine “hot spots” for Medicare fraud. Two of those locations — Miami and Tampa — are located in Florida.

What types of new measures are required? New rules that have been implemented through the Affordable Care Act and other legislation now require certain health care providers and suppliers to undergo additional inspections. These include on-site visits. Those organizations and providers in particularly high-risk categories may be subject to criminal background checks based on fingerprint data, in addition to other invasive evaluations.

What about fraud prevention efforts? CMS has started to research predictive modeling technology that could be used to identify high-risk providers and analyze billing discrepancies. An existing program is already in use through the Fraud Prevention System, which uses predictive technology to analyze billing and compensation data. The FPS has been using this technology to screen Durable Medical Equipment claims, along with those related to both Medicare parts A and B since 2011. Further, 10 states are participating in the initial launch of the Medicaid version of this fraud prevention effort.

So, what does this mean for me? The federal and state government fraud detection programs are cracking down more than ever on actions that could even be perceived as fraud. This means that a growing number of defendants could find themselves facing allegations of fraud in Florida courts because of improved criminal data analysis. Criminal defendants should be aware of this aggressive prosecution approach.

Source: U.S. Department of Health and Human Services, “Anatomy of a Fraud Bust: From Investigation to Conviction” Sep. 22, 2014

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