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Life Health > Health Insurance > Health Insurance

NAIC Waiting for CMS Antifraud Guidance

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WASHINGTON BUREAU — The National Association of Insurance Commissioners (NAIC) and the U.S. Department of Health and Human Services (HHS) are still in the preliminary stages of developing antifraud measures required by the Patient Protection and Affordable Care Act of 2010 (PPACA).

The Antifraud Task Force at the NAIC, Kansas City, Mo., took up the topic earlier this month during a teleconference scheduled to replace an NAIC summer meeting session that was canceled due to Hurricane Irene.

Fraud wastes at least 3% of all health care spending each year and may waste as much as 10%, according to the National Health Care Anti-Fraud Association (NHCAA), Washington.

In a letter dated May 31, HHS Secretary Kathleen Sebelius asked the task force to develop a model uniform reporting form and recommend uniform reporting standards insurers can use to report fraud and abuse to state insurance departments or other agencies.

Even though the task force convened later than it expected, it is still waiting for guidance from HHS’s Centers for Medicare and Medicaid Services (CMS), industry and government sources said.

“At this time, members are waiting to hear back from HHS/CMS on some of our questions before we make any changes to the existing Uniform Fraud Reporting Form,” said NAIC spokesman Scott Holeman.

Brian Cook, a spokesperson for CMS, confirmed that assessment. “CMS is still working on this guidance,” he said.

The CMS antifraud reporting standards point person acknowledged on the call that he is relatively new to the assignment and has to get up to speed on the NAIC’s current system, sources said.

The NAIC already has a well-developed Online Fraud Reporting System. The system went live in September 2005, and a great majority of states and territories now use it.

Ted Clark, the Kansas Insurance Department’s antifraud director and head of the NAIC’s Antifraud Task Force, said he thinks HHS-NAIC collaboration will happen under a new group.

Clark anticipates a new NAIC working group to be created just for this HHS-NAIC uniform fraud reporting form and standards effort.

He said there are three options on the table: Starting over, modifying or tweaking the existing form, or using the current form.

“We will get input and guidance from CMS to make sure the format is useful for the public payers’ side and the private payers’ side,” Clark said. He said he is “very hopeful that in the end the result will be a public-private partnership in fighting health care fraud,” but that it “will take some time.”

Other health anti-fraud coverage from National Underwriter Life & Health:


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