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Insurance Providers, Government, Law Enforcement Work Together To Fight Health Care Fraud

posted by Alicia Caramenico

on April 22, 2019

The Healthcare Fraud Prevention Partnership (HFPP) uses data sharing and collaboration to protect consumers from health care fraud.

Health care fraud costs tens of billions of dollars each year, resulting in higher health care costs and taxes for everyone. Even worse, the victims of health care fraud may receive inferior and potentially harmful care. Every dollar of health care fraud, waste, and abuse the Partnership recovers or prevents is a dollar of health care premiums or taxes saved for consumers and taxpayers. Every provider delivering unnecessary or inappropriate services that the Partnership uncovers keeps patients safer.

As part of our commitment to combatting fraud and protecting patients, AHIP is a founding member of the Healthcare Fraud Prevention Partnership (HFPP), a public-private partnership. AHIP spoke with Dan Kreitman, the HFPP’s Program Director, about how the Partnership’s data sharing and claims analysis are cracking down on fraud.

What is the Partnership all about?

Daniel Kreitman: The Partnership fosters a proactive approach to detecting and preventing health care fraud through data and information sharing. We work with federal and state agencies, law enforcement, private health insurance providers, and health care anti-fraud associations.

How is the Partnership making a difference now?

Kreitman: We are using cross-payer data analysis—Medicare data, state Medicaid data, and private payer data—to look at billing patterns. Nowhere else in the world is there a health care claims data environment as robust as the HFPP’s cross-payer collection of health care payment data.

And we’re collaborating to fight fraud, waste, and abuse through our regional information sharing sessions. We get together face-to-face with partners at the federal, state, and local levels to talk about fraud, waste and abuse going on in different regions of country. One health insurance provider might be looking into a provider and learn that another insurance provider is also looking into that same provider, and they can get together to collaborate.

What are the top priorities of the Partnership?

Kreitman:  Our purpose is to improve the detection and prevention of health care fraud. Top priorities include exchanging data between the public and private sectors, leveraging analytic tools, and providing a forum for leaders to share their successful and effective methodologies.

If a health insurance provider is not yet a member of the Partnership, what are they missing?

Kreitman: They are missing out on being able to utilize the studies we produce, and the training and collaboration we provide among our partners.

The studies we produce are ground-breaking as to what’s going on right now with fraud, waste, and abuse. The Partnership has more paid health care claims data that anyone else in the world. This allows us to look at providers that are billing Medicare, Medicaid, and private payer levels.

If a health insurance provider is a member of the Partnership but not sharing data, they still get provider alerts and can participate in regional info-sharing sessions. But when we conduct our studies, they won’t see their data and/or the fraud, waste, and abuse patterns in their organization’s data.

What would you say to health insurance providers regarding the privacy and security of payer data shared with the Partnership?

 Kreitman:  The Partnership has one of the highest security protocols under the federal government for protecting health care data. We work with every partner individually to get their data and are flexible in what we receive and how we receive it. Whether the data is de-identified before companies send it or companies send us data and we scrub the data of PII (personally identifiable information) and PHI (protected Health information), we can do it.

We also have our own robust data security and infrastructure teams. We take data security extremely seriously.

What are the biggest challenges facing the Partnership?

Kreitman: We have been in a hypergrowth phase for the last year and have a tremendous amount of data. We’re looking at ways to scale down data to use in the most beneficial way, at the local or regional level. One of biggest challenges is scaling investigations so our partners can use them in looking for fraud, waste, and abuse in their data. That’s an import process.