By Bill Mercer

Last month, Secretary Sebelius and Attorney General Holder announced a new collaboration with health insurance companies to provide both government and private payer claims data to a third-party to detect overpayments and fraud.

http://www.hhs.gov/news/press/2012pres/07/20120726a.html

http://www.justice.gov/opa/pr/2012/July/12-ag-926.html

By pooling claims data and having the third-party analyst look for suspicious billing patterns, the federal government and participating insurers believe outliers would be readily identifiable.  Claims data which appear to suggest the existence of fraud or overpayments would be referred to federal law enforcement for further investigation.

By commingling claims information from private insurers, Medicaid, and Medicare, the Administration believes it could detect, for example, a provider who bills all payers for more than 24 hours in a day or bills the same claims to multiple insurers.  Attorney General Holder’s statement [http://www.justice.gov/iso/opa/ag/speeches/2012/ag-speech-120726.html] refers to the prospect of detecting claims made to multiple public and/or private insurance plans for the same patient on the same day in more than one city.

A number of private sector participants have volunteered to participate in the partnership, including:

America’s Health Insurance Plans

Amerigroup Corp.

Blue Cross and Blue Shield Association

Blue Cross and Blue Shield of Louisiana

Humana Inc.

Independence Blue Cross

Travelers

Tufts Health Plan

UnitedHealth Group

WellPoint Inc.

Significant details necessary to the creation of a functional partnership have yet to be resolved.  According to the HHS press release, the Executive Board and two committees will meet for the first time next month.  The initial work plan is also a work-in-progress.

The partnership received support from Senator Coburn and Senator Hatch, who wrote to the Acting Administrator of CMS that “this is an effort which is long overdue.”  [http://www.coburn.senate.gov/public/index.cfm?a=Files.Serve&File_id=b3d5048d-a395-49af-b4ac-2c2b65b9a4a0]  The lack of detail in the Administration’s rollout of the initiative generated a series of follow-up questions from Senators Coburn and Hatch.  They have asked for responses on the following issues by the end of August:

“Specifics regarding exactly how this collaboration will work including what entities will be involved, whether HHS/CMS or another entity will be overseeing the effort and a timeline for expected key milestones of the effort.

A step-by-step explanation of how the information will be shared (e.g., what systems will be used to transmit the data), what authorities allow the exchange of information, what impediments exist to sharing information (e.g., statutory language) and where the information will be stored/analyzed.

A description of the third party who will be analyzing the data, as well as an explanation of how that entity will be selected and what their capabilities are to integrate and analyze such a large amount of information.

Specifics regarding what will happen when leads are identified, how that information will be disseminated, and what the process will be for following up on those leads.”

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