Feds and insurance companies to share database info to combat health care fraud

Eric Holder and Kathleen Sebelius

President Obama and health insurance executives plan to announce a new joint effort…to crack down on health care fraud by sharing and comparing claims data…

The charter for the venture says that federal investigators and insurers will pool claims data and look for suspicious billing patterns and aberrations. If agents detect possible fraud and begin an investigation, they can provide insurers with the names of doctors, hospitals and suppliers suspected of misconduct.

The claims data will come from Medicare, Medicaid and private insurance.

“The more claims data we have, the more effective we can be in analyzing and using it,” said an administration official working on the project.

For example, the official said, the new venture could identify a doctor who bills Medicare and two private insurers for a total of more than 24 hours of work in a single day.

“Seen separately,” the official said, “these billings could appear normal. Sharing information among payers brings this potentially fraudulent activity to light so it can be stopped…”

“Most of the criminals who prey on the nation’s health care system are equal opportunity thieves,” Mr. Morris said. “They defraud private health insurance as well as federal programs like Medicare and Medicaid…”

Medicare receives more than a billion claims a year from doctors, hospitals, pharmacies, suppliers of medical equipment and other providers. Increasingly, the government uses “data mining” techniques to identify providers and claims that pose the greatest risk of fraud…

Computational analysis rocks! Even when it’s years overdue.

The article makes the point more than once that antipathy between the Obama Administration and insurance companies is a big wall to overcome in the establishment of this procedure. Bogus. If insurance companies cared about the detail work required to build this sort of cooperation they could have done it with Bush when he was in office.

True – Bush didn’t press for anything to do with eliminating Medicare fraud. Neither did the insurance companies. Since they’re getting paid whatever they ask – by the Feds which means us – they didn’t give a damn. Now, they will be pressed into acting like responsible companies. A tough new task for American insurers.

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