Anti-fraud collaborative efforts
Overview of industry & government initiatives
Alam Singh
III Workshop on HI fraud
Agenda
 Overview of anti-fraud initiatives in health insurance
–
US
–
Other markets
 Niche initiatives
 Auto insurance initiatives
 Key learnings
2
Overview of major industry initiatives in US
USD 2 trillion healthcare expenditure annually in US, fraud estimated vary, reasonable
estimate at USD 6-8% or USD 120 – 160 billion.
 National Health Care Anti-Fraud Association (NHCAA): A public – private partnership
founded in 1985, 150+ private health insurers and federal and state government
members and 500 individuals. Goals: education & training, collaboration, dialogue.
 Coalition Against Insurance Fraud: a coalition of insurance organizations, consumers,
government agencies and legislative bodies formed in 1993. Promotes anti-fraud
legislation and public education (ie: scam warnings, how to report fraud, and how to
protect themselves).
The Patient Protection and Affordable Care Act, 2010, includes new anti-fraud and abuse
provisions, strengthens the federal False Claims Act (e.g., by allowing broader sources of
information to bring a whistleblower suit) and the Anti-Kickback Statute. New requirements
regarding return of overpayments, additional federal funding and enforcement powers to
fight fraud and abuse, and increased criminal and civil penalties.
3
Overview of major government initiatives in US
Primarily focus on Medicare and Medicaid fraud. HIPPA ‘96 included provision for creating a
Health Care Fraud and Abuse control program (HCFAC). Multi-prong program with RoI
focus, since inception about USD 4.9 recovered for 1 spent, latest 3 year average USD 6.8.
Initiatives include StopMedicareFraud.gov, HEAT teams & whistleblower program.
:
4

Health Care Fraud Prevention and Enforcement Action Team (HEAT): Medicare Fraud
Strike Force, includes federal, state and local investigators. Based in fraud prone areas and
currently managing 2400 concurrent investigations. Can conduct highly sophisticated
investigations and frequently focus on scams conducted by organized crime, ie:

115 people, 9 cities, USD 240 million in false billings

91 people, 8 cities, USD 290 million in false billing

Dedicated prosecution teams and strong sentencing guidelines:

Conspiracy to commit health care fraud, maximum 10 years / $250,000 fine.

Submission of false claims to the Medicare, maximum five years. (example)

Medicare & Medicaid Fraud Reporting Center: offers whistleblower rewards that allow
healthcare professionals to collect upto 30% of the fines government collects, sometimes can
be millions of dollars.
Major industry initiatives, other markets
Mixed healthcare systems in Canada, EU & UK, public delivery to government run
insurance program and private insurance. Thus a broader focus on “healthcare” fraud.

The Canadian Health Care Anti-fraud Association (CHCAA): Founded in 2000,
goals are to educate and create awareness, build public - private partnerships with law
enforcement, health regulatory bodies, consumer groups, and provider associations.

The European Healthcare Fraud & Corruption Network (EHFCN): Established in
2005, pan European network represents 25 member associations in 15 countries,
EHFCN provides information, tools, training and assistance in fighting fraud.

The Health Insurance Counter Fraud Group UK (HICFG): membership consists of
health insurance companies and is supported by the Association of British Insurers and
NHS Counter Fraud.

NHS Counter Fraud (UK): 300+ counter fraud specialists in the NHS, providing
oversight to a GBP 100 billion budget.
All of the above are members of Global Health Care Anti-Fraud Network (GHCAN). Working
cooperatively to improve international standards of practice around fraud prevention.
5
Overview of niche initiatives

International Association of Special Investigations Units (IASIU): founded in 1984,
non-profit organization to coordinate effort within the industry to combat insurance fraud
and providing education and training for insurance investigators.

Pennsylvania Fraud Prevention Authority: a regional initiative, created by a state
assembly act with sole purpose is to combat insurance fraud throughout the state.
Funded by levy on all insurance companies. Commits approx. USD 10 million annually
to 16 law enforcement agencies and USD 2 million each year in public education.
Creates a quarterly newsletter which is case study based. (example)

National Insurance Crime Training Academy (NICTA): National Association of
Independent Insurers (NAII) & National Insurance Crime Bureau (NICB) jointly with FBI
Academy and the National White Collar Crime Center initiated this project. It is web
based and trains insurance personnel and law enforcement officers to increase the
deterrence, detection, investigation and prevention of fraudulent claims.
6
Overview of auto insurance initiatives
 National Insurance Crime Bureau (NICB): Not for profit structure with a focus on auto
insurance, with 1,100 members (P&C insurers, rental and transportation related
companies). Over 300+ employees. Famous for VINCheck.
 Auto theft prevention authorities (ATPA): in USA, Canada & Australia, mostly
organized at state level. Funded by contribution ranging from USD 1 – 10 per vehicle per
year collected from owners by insurers. Goal is to foster partnerships amongst auto
crime prevention organizations and agencies, access to information, coordinate a unified
front in auto crime prevention. Identify local, state and national trends regarding auto
crimes.
 Insurance Institute for Highway Safety (IIHS) & The Highway Loss Data Institute
(HLDI) & Insurance Research Council (IRC): all non-profit and supported by insurers.
 IIHS is dedicated to reducing the losses from crashes on the nation's highways.
 HLDI studies data to present losses resulting from the ownership and operation of
different types of vehicles and by publishing insurance loss results by vehicle make
and model.
 IRC conducts public opinion surveys, analysis of insurance statistical experience,
closed claims studies (on auto injuries) and simulation studies.
7
Common attributes
Goals






Measure & educate
Deter & prevent
Detect & investigate
Prosecute / sanctions
Recovery
Create a real anti-fraud culture: within service providers, medical suppliers, payers,
users and policy makers.
Methods





8
Educate to increase public awareness
Sharing of good practices, development of common working standards
Data analysis
Providing information, tools, training and assistance
Collaborate
Questions?
9