JIFA: Celebrating 10 years of combating fraud, waste and abuse

Posted by Kendra Smith
The latest JIFA edition comes from Daniel Kreitman, Program Director, for the Healthcare Fraud Prevention Partnership.

By Daniel Kreitman | September 1, 2022

For years, health care fraud professionals recognized the benefits of collaborating among payers to detect fraud, waste and abuse. Understanding the need and benefits collaboration would provide, the U.S. Department of Health and Human Services and the U.S. Department of Justice announced the creation of the Healthcare Fraud Prevention Partnership on July 26, 2012. The Coalition Against Insurance Fraud was one of the founding members

Supported by a Trusted Third Party that collects and protects member data, the HFPP became the first public-private partnership focused on curbing health care fraud by acquiring claims from its members to develop a cross-payer database. 

This year, the HFPP celebrates its 10th year as a leader in strengthening the nation’s fight against health care fraud, waste and abuse. Over the last 10 years, the Partnership has helped detect and prevent healthcare fraud through data and information-sharing, observes Chiquita Brooks-LaSure, Administrator, Centers for Medicare and Medicaid Services. 

The HFPP applies analytics to Partner data to identify previously unseen fraud. By uniting public and private sector health care claims into a unified cross-payer data set, the HFPP has brought a new nationwide approach to combat fraudulent, abusive and wasteful spending.  

The HFPP’s mission is to protect the public by identifying and reducing health care fraud, waste and abuse through collaboration, data- and information-sharing, and cross-payer research studies. The HFPP delivers actionable data to Partners to develop strategies that disrupt existing and emerging fraud trends, and contribute to cost savings.

HFPP unites anti-fraud efforts

Over the last 10 years, the HFPP has helped change how health care organizations unite anti-fraud efforts by combining public and private health care claims data for enhanced analysis and heightened insights into fraud.

The Partnership began by identifying the types of claims data needed to enable innovative analytics, creating a secure data warehouse, and establishing a comprehensive process for secure Partner-data sharing. Organizations soon realized the value of the HFPP. Over the last decade, the Partnership has grown from its initial 21 Partners to over 250 organizations. This demonstrates their belief in the HFPP’s mission of working together to combat fraud, waste and abuse. 

“We were the first Medicaid Fraud Control Unit to join the HFPP because we recognized then, just as we do now, that the HFPP is the future of health care fraud prevention, detection and enforcement,” says Lloyd S. Early, Special Agent-In-Charge, Office of Ohio Attorney General. “The HFPP is built on the premise that success will require public-private partnerships and coordination by and among government entities with complimentary program integrity responsibilities. The HFPP embraces a proactive approach to fraud detection and coordinated responses to aberrant medical provider behavior.” 

Since 2012, the HFPP has continually improved and expanded its ability to identify billions of dollars in potential health care fraud, waste and abuse. In addition, through the HFPP’s Partner-to-Partner information-sharing process, hundreds of medical providers have been identified for further review (pre-pay, medical and investigation development) or excluded from participating in payer networks such as Medicare and Medicaid. 

“Congratulations to the HFPP for 10 years of dedicated service, and for being a conduit in sharing information about fraud, waste and abuse,” says James R. Brown, Special Investigations Unit Manager for Anthem.

Delivering valuable fraud information

Since the HFPP’s inception, the Partnership has delivered valuable information and cross-payer analyses of health care claims data to organizations across the U.S. With more Partners joining and sharing their data, HFPP studies have become increasingly complex and diverse. They are providing enhanced analytical insights to support member organizations’ anti-fraud efforts. HFPP studies offer clearer visibility into existing and emerging schemes, thus providing actionable outcomes and the recovery of funds to its HFPP Partners. 

The Partnership began analyzing professional claim types before expanding in 2019 to include institutional claims. In 2021, the Partnership added pharmacy claims data for more varied analytics. The HFPP now analyzes against adjusted claims for further accuracy when detecting potential industry-wide fraud schemes. We continue to add billions of lines of claims data to the HFPP Data Warehouse each year for more in-depth insights. 

As the Partnership grows, so do the studies offered to its members. The variety of studies is increasing with new and previous iterations. They include analytics related to COVID-19-related billing vulnerabilities, and enriched reporting to assist law enforcement in lead generation and corroborating evidence. The HFPP’s unparalleled dataset evaluates multiple key variables, and annually supports analysis for at least 16 studies. 

The HFPP’s dataset also supports the creation of HFPP white papers and issues papers where Partners collaborate by sharing their experiences, best practices and challenges on topics of interest. Past white paper and issue paper topics have focused on services involving COVID-19, genetic testing and recovery treatment.

HFPP studies latest fraud trends

The HFPP’s vast dataset has allowed the Partnership to conduct diverse studies on the latest healthcare fraud trends. In the last six months alone, five HFPP studies have identified more than $4 billion of potential exposure dollars. Two studies responded to the challenges reported by Partners about the public health emergency of COVID-19, and the lack of standardization of Applied Behavioral Analysis (ABA) billing codes.

During the pandemic, regulatory flexibilities were implemented to ensure that necessary care could continue to be delivered effectively to Americans. However, dishonest medical providers exploited national efforts to increase access to diagnostic testing. These providers fraudulently and wastefully billed for expensive and unnecessary tests. In response to Partners’ desire to understand their exposure to these schemes, the Trusted Third Party created a study focused on COVID-19 Add-On Laboratory Testing. The study analyzed when Respiratory Pathogen Panels (RPPs), genetic tests, antibody tests and others were added to existing COVID-19 tests.

In April 2022, as COVID variants emerged, the HFPP published a second iteration of the COVID-19 Add-On Laboratory Testing Study, as it remained an investigative priority for Partners. The HFPP identified $551 million of potential exposure dollars for add-on testing (focusing on Partner data from March 1, 2020 through Jan. 31, 2022).

For instance, one laboratory billed RPP add-on tests for 45% of its patients who received a COVID-19 test, and was paid over $3.5 million during the study period. Patients of this laboratory were 3.5 times more likely to have an RPP testadded to their COVID-19 test when compared to all other labs. As shown in Figure 1 below, the study examined schemes involving providers billing for COVID-19 testing and added tests across five billing scenarios. The highest potential exposure dollars were identified in Scenario 3, reflecting respiratory add-on testing. 

COVID-19 Add-on Laboratory Testing Study

Figure 1: Study Results, Scenarios and Exposure Dollars

In the second HFPP study example — Applied Behavioral Analysis — the HFPPanalyzed claims data and identified questionable billing patterns due to the growing concern that significant vulnerabilities exist in safeguards to ensure allocated resources for ABA are used appropriately and not misdirected into fraud waste or abuse. Many factors contribute to the challenges of monitoring ABA through claims data collection, including:

  • Absence of national or local coverage determinations. 
  • Wide variations across state regulations.
  • Payer policies that govern the types of therapists or other licensed healthcare professionals that provide specific ABA services.
  • Lack of standardized billing codes and modifiers. 

The HFPP analyzed claims from Jan. 1, 2018 through Dec. 31, 2021, and identified suspicious billing reported across five scenarios based on potential dollars at risk (see Figure 2 below). 

Overall, the HFPP identified $1.1 billion of potential exposure dollars, with the largest exposure of $525.7 million in billing Scenario 2 (ABA Services greater than 40 hours per week for members more than three years of age or unknown age). Drilling further into the results, the HFPP identified 87 high-exposure National Provider Identifiers flagged for over $1 million each, with impacts ranging from one to nine Partners. Eight rendering NPIs flagged in the study were also previously flagged in another HFPP Study, Self-Care/Home Management. 

Applied Behavioral Analysis Study

Figure 2: Total Potential Exposure Dollars Identified

The COVID-19 Add-on Laboratory Testing Study and ABA Study are just two examples of HFPP studies revealing the latest fraud health care trends. HFPP Partners that shared data in these studies received providersinvolved in the potential fraud schemes identified. Non-participatingPartners received summary reports detailing the overall billing results. Note that the HFPP does not conduct investigations. When a Partner uses a lead from HFPP studies analysis, they must determine, based on their data, if there is an issue with a specific provider. 

HFPP partner liaison program

The Partnership also offers personalized support to members through the HFPP Partner Liaison Program. Health care fraud, waste and abuse industry experts are referred to as HFPP Partner Liaisons. They assist each Partner’s fraud-fighting efforts, and help Partners leverage the power of the HFPP’s extensive health care anti-fraud network. 

HFPP Partner Liaisons maintain consistent communication with Partners, keeping them informed about the latest information on health care industry fraud, HFPP studies and upcoming anti-fraud events. They, along with HFPP Partners, present HFPP study findings at anti-fraud industry events and promote the benefits of HFPP membership. Every Partner is assigned an HFPP Partner Liaison who supports member needs in varied functions. This includes data-sharing and information exchange, identifying actionable leads, and small-group discussions on fraud, waste and abuse.

Continuing fraud-fighting efforts

Diverse perspectives and approaches are informing the future of the HFPP. The Partnership provides healthcare payers an opportunity for increased collaboration and tools to raise awareness of healthcare fraud, waste and abuse. The HFPP prioritizes the potential for reducing patient harm, and ensures valuable resources are spent on delivering care instead of fraudulent spending. 

As the HFPP grows, it will continue providing valuable data and resources to members across the U.S. The HFPP is making great strides in health care with increased data-sharing, amplified diversity in studies, and a heightened sense of unity. Aggressive actions confronting health care fraud are growing more-robust through the HFPP’s collective efforts.

Joining the HFPP enables organizations to meaningfully contribute to reducing health care fraud by collaborating with leading anti-fraud experts, obtaining industry best practices and investigative leads, and gaining insights at educational and information-sharing events. At no cost, Partners can leverage their collective experiences and data to expand and innovate fraud-fighting initiatives across federal, state and private organizations. 

Join the HFPP

The HFPP can enhance your fraud-fighting efforts. Watch the HFPP video and visit our homepage to find out how to become an HFPP Partner. If you would like to join the HFPP or have questions, contact the HFPP at [email protected] or 1-888-652-1037.

About the author: Dan Kreitman serves as the Program Director responsible for the over-sight of HFPP’s Trusted Third Party. The Partnership is a voluntary public-private partnership between the federal government, state agencies, law enforcement, private health insurance plans and healthcare anti-fraud associations that aims to foster a proactive approach to detect and prevent healthcare fraud through data and information sharing.

Before assuming this role, Mr. Kreitman served as the Director of Special Investigations in the Compliance Division at Centene Corporation. He oversaw investigations associated with alleged or suspected fraud, waste, and abuse; ensured compliance with relative contractual requirements; assessed controls designed to mitigate financial and operations risks; and evaluated the effectiveness of operations. Mr. Kreitman also focused on developing and leading large scale Special Investigations Units (SIUs) for managed care organizations with an emphasis on Medicare and Medicaid operations, including the development of a 5 Star Medicare Advantage SIU.