Blues fraud crack­down nets $510 mil­lion in 2009

$510 mil­lion re­cov­ered in 2009 as in­sur­ers adopt new strate­gies

Modern Healthcare - - Editorial - Gregg Blesch

With so much hand-wring­ing about health­care spend­ing, the peo­ple who pay health in­surance claims say they’re com­mit­ted to spend­ing less on mak­ing crim­i­nals rich. Blue Cross and Blue Shield com­pa­nies saved or re­cov­ered $510 mil­lion in 2009 through anti-fraud ef­forts, ac­cord­ing to a sur­vey of mem­bers com­pa­nies con­ducted by the Blue Cross and Blue Shield As­so­ci­a­tion.

Fraud in­ves­ti­ga­tions pre­vented the com­pa­nies from pay­ing $318 mil­lion in bo­gus claims, a 62% in­crease from 2008 cred­ited to more at­ten­tion and technology ded­i­cated to the prob­lem. The in­ves­ti­ga­tions al­lowed the com­pa­nies to get back $192 mil­lion that had gone out the door. The Blues re­ceived 5,028 com­plaints and re­ferred 1,044 of them to law en­force­ment, lead­ing to 355 con­vic­tions, ac­cord­ing to the sur­vey.

To an­nounce the find­ings, the as­so­ci­a­tion con­vened a news con­fer­ence that in­cluded Peter Budetti, who in Fe­bru­ary was named di­rec­tor of the CMS’ Cen­ter for Pro­gram In­tegrity. Budetti noted that HHS this year hosted a health­care fraud “sum­mit” aimed at pool­ing fraud-fight­ing strate­gies be­tween the govern­ment and pri­vate in­sur­ers.

Budetti said the CMS is work­ing with com­pa­nies on ways to im­prove in­for­ma­tion- shar­ing and an­a­lyt­ics. “We are very com­mit­ted to work­ing with the pri­vate sec­tor be­cause we rec­og­nize that it’s the same peo­ple who are out there cre­at­ing prob­lems that are on the pri­vate side or on the pub­lic side—they don’t dis­crim­i­nate,” Budetti said. He added that the govern­ment is work­ing to do a bet­ter job keep­ing crim­i­nals from en­rolling as providers and sup­pli­ers and iden­ti­fy­ing bo­gus claims be­fore they’re paid.

“Sure we should chase af­ter them,” Budetti said. “We also want to fo­cus on pre­vent­ing those prob­lems in the first place and that’s a big part of our new ini­tia­tives at the Cen­ters for Medi­care and Med­i­caid Ser­vices.”

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