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Life Health > Health Insurance > Health Insurance

PPACA: Panel Plans Health Fraud Reporting Tool

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A panel at the National Association of Insurance Commissioners (NAIC) is trying to come up with a version of the Online Fraud Reporting System that suits the needs of private health insurers.

The Uniform Fraud Reporting Form Subgroup, part of the Antifraud Task Force at the NAIC, Kansas City, Mo., considered proposals for extending the reporting system last week at an NAIC interim meeting in Washington.

The subgroup and the task force are helping the NAIC implement a section of the Patient Protection and Affordable Care Act (PPACA), a component of the Affordable Care Act package, that requires insurance regulators to develop a model uniform reporting form for private health insurers that want to report suspected fraud and abuse to state agencies.

“The current [fraud reporting system] form (adopted in 2003) seems to us to be predominantly focused on property and casualty insurance,” Louis Saccoccio, executive director of the National Health Care Anti-Fraud Association, Washington, and Byron Hollis, an anti-fraud program director based in the Washington office of the Blue Cross and Blue Shield Association, write in a letter to the task force.

Etico L.L.C., Milwaukee, a health insurance anti-fraud firm, says a fraud reporting system could include a menu of allegations that could include choices such as “services not rendered,” “upcoding,” “identity theft,” “patient recruitment/kickbacks,” “misrepresentation of non-covered treatment,” “lack of medical necessity,” and “misrepresentation of eligibility/patient identity.”

Saccoccio and Hollis note that PPACA requires officials at the U.S. Department of Health and Human Services to work with the NAIC to develop uniform reporting standards for referrals of suspected health care fraud and abuse as well as an online reporting system.

“Ideas that could be explored include providing guidance to private insurers as to at what stage a referral should be filed (complaint stage, at the completion of the investigation, when evidence suggests potential fraud, etc.), defining the purpose of filing a referral (to collect intelligence, facilitate an investigation, etc.), defining the purpose for collecting certain types of data (i.e. settlement amounts, etc.), explaining how the data collected will be used and if it will be shared with private insurers in any capacity, etc.,” Saccoccio and Hollis say.


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