Reducing fraud and abuse in health care and insurance
Health reform helps reduce fraud and abuse by preventing fraud, getting tougher on criminals, and using better data to identify potential fraud. Every dollar of waste and fraud is one less dollar going toward affordable health care. All Minnesotans deserve to know our insurers, health care providers, and state government are good stewards of our dollars, and will not tolerate those that misuse them.
- Are penalties for increased under health reform?
Yes, health reform increases the federal sentencing guidelines for health care fraud offenses by 20-50 percent for crimes that involve more than $1 million in losses. The law establishes penalties for obstructing a fraud investigation and makes it easier for the government to recapture funds from fraudulent practices. And the law makes it easier for the Department of Justice (DOJ) to investigate potential fraud or wrongdoing at facilities like nursing homes.
- How do we find fraudulent providers and suppliers?
The first step to fighting fraud is better screening of providers and suppliers. Before a new health care provider or supplier can be paid by Medicaid or Medicare, they must meet new, stricter enrollment standards under health reform. If fraud is suspected, Medicare payments to providers or suppliers can be suspended. This will move Medicare away from a “pay and chase” mode of having to track down fraudulent payments after the fact. Health reform also requires Minnesota to withhold payments to Medicaid (Medical Assistance) providers if there is a credible allegation of fraud.
It is also critical that states and the federal government work together. Health reform ensures that fraudulent providers and suppliers cannot move from state to state or between Medicare and Medicaid. Minnesota and all states are required to terminate anyone who has been terminated by Medicare or by another state. Under the health reform, state and federal government must work together to coordinate anti-fraud efforts.
Fighting fraud requires data. Health reform requires certain data from Medicare, Medicaid and CHIP, the Veterans Administration, the Department of Defense, the Social Security Disability Insurance program, and the Indian Health Service to be centralized, making it easier for agency and law enforcement officials to fight fraud system-wide. Investigators and law enforcement will also have better access to real-time data so they can more quickly detect and prosecute fraud schemes.
- What if a provider is considered at high-risk of committing fraud?
If a health care provider is considered at high-risk for committing fraud, health reform allows the government to ask more questions and screen them before paying for services in public programs. If a provider is not considered trustworthy, the government may choose to not allow them to participate in Medicare and Medicaid.
- What happens if the government accidentally pays a provider too much?
If a health care provider, supplier, Medicare Advantage plan, or Part D plan is paid too much from Medicare or Medicaid by error, they are required to return the extra money. Returning these funds hasn’t always been well enforced but under health reform these entities are clearly required to report and return Medicare and Medicaid overpayments within 60 days of identification.
- What about private insurers?
Health reform also provides enhanced tools and authorities to address abuses of multiple employer welfare arrangements and protect employers and employees from insurance scams. It also gives new powers to the government to investigate and audit the health insurance exchanges.
- What is Minnesota doing to fight health care fraud in our state's public health care system?
The Minnesota Board on Aging trains older Minnesotans to identify and fight fraud in health care. For information on being trained, please contact the Board on Aging.
The Minnesota Department of Human Services also recently formed the Office of the Inspector General to be the primary entity responsible for preventing and recovering fraud in Minnesota’s public health care system. The Office of the Inspector General’s job is to uncover fraud and then notify County Attorney’s and the Attorney General for prosecution.
- What should I do if I suspect fraud?
Anyone who suspects public assistance fraud can report it anonymously.
For suspected fraud involving health care providers
• Twin Cities metro
• Toll-free line
For suspected fraud involving recipients of cash assistance, child care assistance, food support and health care
• Twin Cities metro
• Toll-free line
For suspected fraud in private insurance
Fraud Tip Line
1-888-FRAUD MN or
For more information about fighting fraud in private insurance
Minnesota Department of Commerce
For information on how well Minnesota is fighting fraud
Minnesota Department of Human Services: Program Integrity - Recovered Funds
For information on federal anti-fraud efforts
HealthCare.gov Newsroom - Fraud