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California Passes Bill to Beef-Up Health Anti-Fraud Prosecution

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The busy California State Legislature has passed Assembly Bill 2138, which would in some cases double the current annual assessment of 10 cents per insured paid by health and disability insurers to up to 20 cents per insured, fueling efforts by local district attorneys to investigate and prosecute health and disability insurance fraud throughout the state. 

Health and disability insurance fraud is a continuing and critical problem for policyholders, providers, insurers, and California’s economy. The National Health Care Anti-Fraud Association (NHCAA) estimates that the financial losses due to health care fraud are in the tens of billions of dollars each year nationwide.

From 2007 to 2010, the California Department of Insurance (CDI) received more than 6,000 health and disability-suspected fraudulent claims statewide, with a fraction of those claims referred to the local district attorneys. They were only able to conduct 656 investigations from these claims.

Indeed, fraud is a nationwide problem. The U.S. Senate Finance Committee here in Washington held a hearing in April titled “Anatomy of a Fraud Bust: From Investigation to Conviction,” sponsored by Committee Chairman Senator Max Baucus, D-Mt., to provide resources to states to fight health insurance fraud. One case the hearing spotlighted was a nationwide health care fraud case involving 91 defendants and nearly $300 million in fraudulent billing. 

The development of this case, made public in September 2011, was the result of collaborative work among government agencies responsible for combating health care fraud including, the Centers for Medicare & Medicaid Services (CMS), the U.S. Department of Health and Human Services (HHS), the Office of Inspector General (HHS-OIG), and the U.S. Justice Department (DOJ),” said the NHCAA.  

Baucus noted in April the advances that have been made in identifying and fighting fraud in the Medicare program, highlighting the tools and resources enabled by the PPACA, NHCAA wrote.    

“I am pleased that the State Legislature passed this bill giving local communities the necessary resources to fight the growing problem of insurance fraud,” said California Insurance Commissioner Dave Jones today. “This type of fraud hurts everyone from policyholders to providers, and, unfortunately, it is becoming more sophisticated. I applaud Assembly Member Blumenfield for authoring this important anti-fraud legislation.”  

In July, the White House announced the new National Fraud Prevention Partnership:

“NHCAA and our members applaud this effort and pledge to continue working closely with the Department of Health and Human Services, the Department of Justice and the other publicprivate stakeholders to make this initiative a success,” NHCAA stated then.

The California legislation has been a long time in coming.  

Several years back, the Department’s Advisory Task Force on Insurance Fraud, made up of law enforcement officials, insurance industry representatives, and consumer advocates, issued a comprehensive report of state anti-fraud insurance programs. The report found, among other things, that the health and disability insurance lines had insufficient policy assessments to support a statewide anti-fraud effort. This led to the recommendation to increase funding in the current bill, AB 2138.