The Healthcare Fraud Prevention Partnership (HFPP) has released its latest white paper, "Measuring the Value of Healthcare Anti-Fraud Efforts" (PDF). Authored by researchers at Boston University, this white paper captures the value of efforts to combat healthcare fraud with a focus on deterrence as an important element of return on investment (ROI). 

Efforts to combat healthcare fraud are critical to the long-term financial sustainability of health insurance programs and patient safety. Payers undertake extensive measures to combat fraud, such as conducting pre- and post-payment reviews, member education, and criminal and civil litigations, as well as enforcing regulations directed at eliminating fraud. When evaluating the effectiveness of these initiatives, ROI is often used as a key metric, measuring net value against costs.

Calculating ROI with the inclusion of deterrence ensures fraud-fighting efforts are properly captured, minimizing the potential of undervaluing such initiatives. Information from HFPP Partner interviews and case studies featuring Medicare claims data reveal that when both the impact of deterrence and recovery are included in financial returns, ROI is higher by a factor of 2 to 10 – even when conservatively measured. 

This HFPP resource outlines detailed strategies to improve ROI measurement for fraud prevention efforts, including moving from a “pay and chase” model to a preventive one. 

For more information, please see:

• Measuring the Value of Healthcare Anti-Fraud Efforts HFPP White Paper (PDF)
• White Paper Information Sheet (PDF)

CMS recognizes that it is important for stakeholders to understand how CMS anticipates performing medical review after the Public Health Emergency (PHE) has ended. Below is an FAQ that addresses how our review contractors (Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and the Supplemental Medical Review Contractor (SMRC)) plan to conduct medical reviews post PHE.

Q. At the end of the Public Health Emergency (PHE) how will CMS’ review contractors conduct medical reviews for claims billed during the PHE based on approved waivers or flexibilities?

A. CMS contractors (MACs, RACs, and SMRC) review a very small percentage of Medicare Fee-for-Service claims each year. During the PHE, flexibilities were applied across claim types. For certain DME items, this included the non-enforcement of clinical indications for coverage. Since clinical indications for coverage were not enforced for certain DME items provided during the PHE, once the PHE ends CMS plans to primarily focus reviews on claims with dates of service outside of the PHE, for which clinical indications of coverage are applicable. We note that we may still review these DME items, as well as other items or services rendered during the PHE, if needed to address aberrant billing behaviors or potential fraud. The HHS-Office of the Inspector General may perform reviews as well. All claims will be reviewed using the applicable rules in place at the time for the claim dates of service.

For more information about medical reviews and the claims process, please visit the Medical Review and Education page.

On July 20, 2022, the Department of Justice announced criminal charges against 36 defendants in 13 federal districts across the United States for more than $1.2 billion in alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and durable medical equipment (DME) schemes.

The nationwide coordinated law enforcement action includes criminal charges against a telemedicine company executive, owners and executives of clinical laboratories, durable medical equipment companies, marketing organizations, and medical professionals. In connection with the enforcement action, the department seized over $8 million in cash, as well as luxury vehicles and other fraud proceeds.

Additionally, the Centers for Medicare & Medicaid Services (CMS), Center for Program Integrity (CPI) announced today that it took adverse administrative actions against 52 providers involved in similar schemes.

“The Centers for Medicare & Medicaid Services continues to aggressively investigate fraud, waste and abuse and has taken action to protect patients, critical health care resources and to prevent losses to the Medicare Trust Fund,” said CMS Administrator Chiquita Brooks-LaSure. “Work like this to combat fraud, waste, and abuse in our federal programs would not be possible without the successful partnership of CMS, the Department of Justice, and the U.S. Department of Health and Human Services Office of Inspector General.”

Read the DOJ press release.