PPACA: Panel Plans Health Fraud Reporting Tool

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.