Move over, Office of Inspector General and Justice Department: Two experts suggest that HHS fight health care fraud more pro-actively by arming contractors with FICO-style software.
 
A new article in the influential journal Health Affairs by Marco D. Huesch and Robert J. Szczerba, both of whom are affiliated with the Leonard D. Schaeffer Center for Health Policy and Economics at USC, acknowledges the strides the federal government has made in fighting health care fraud. (HHS likes to brag on the record-breaking $14.9 billion in fraud it uncovered between 2009 and 2012.)
 
But rather than focus on recoupment, the authors encourage the feds to adopt “the proactive approach championed by CMS’ new director of the Center for Program Integrity … to shift the agency from trying to recoup improper payments and prosecuting criminals to not making such payments in the first place.”
 
How? By using tech-based fraud-control programs, such as those used in consumer banking, which “have reduced losses by more than two-thirds over 20 years,” and by arming contractors with them, the authors suggest.
 
One of their models: FICO, which not only affects consumer credit ratings but can “pre-emptively identify those merchants, customers and transactions that present a statistically higher risk of fraud” via predictive analytics software, thus “preventing a detected potential fraud before or soon after a payment is made” – and stop payment the way banks stop suspicious transactions.
 
Commercial insurers already use these tools, and the authors would like to see the feds “consider the option of revisiting Medicare administrative contractor (MAC) and zone program integrity contractors (ZPIC) contracts to mandate fraud-prevention technology investments.”
 
This would seem to take contractors well beyond the pre-payment edits they currently use to stop payments and effectively make them partners with OIG and DOJ. This might be more cost-efficient for the government, but for providers, it would probably just add to the difficulties of getting paid.
 
For the latest news on the strategies MACs, ZPICs, recovery auditors and commercial payers use to stop fraud, turn to Part B News and Home Health Line.