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Program Integrity: How Much Money Can Combating Health Care Fraud and Abuse Save?

Monday, March 05, 2012

Headlines regularly call attention to pockets of fraudulent activity in the health care area--scams that amount to millions and potentially billions of dollars. The stories typically focus on catching the "crooks" but not so much on efforts to prevent fraud, waste and abuse in health care programs. Both types of efforts are important. With continued concerns about rising health care costs and the current focus on deficit reduction, how much money can be saved and put to better use by reducing waste, abuse and outright fraud?

Initiatives to stop fraud and abuse in health care have been evolving. The Deficit Reduction Act of 2005 created the Medicaid Integrity Program, the first comprehensive federal strategy to prevent and reduce provider fraud, waste, and abuse in Medicaid. The Patient Protection and Affordable Care Act provided new tools to enhance and coordinate CMS' efforts to prevent fraud in Medicare, Medicaid and the Children’s Health Insurance Program. More recent proposals seek to crack down even further on fraud and abuse.

What new challenges arise as states move from fee-for-service Medicaid to managed care initiatives? Is lack of coordination between state Medicaid agencies and their Medicaid Fraud Control Units hampering program integrity efforts? Have some states conquered this problem? Are Medicaid agencies adequately staffed to deal with fraud and abuse? What are some private sector efforts in fraud control? How are Medicare beneficiaries and providers collaborating with HHS? How can advanced information systems enhance fraud control efforts in public and private programs?

To address these questions and more, the Alliance for Health Reform and the Centene Corporation sponsored a March 5 briefing. The focus was not so much on the criminal aspect of the problem, but rather on how to coordinate the efforts of Medicaid, Medicare, the private sector and others to prevent and combat the waste, fraud and abuse. Panelists were: Peter Budetti, director of the Center for Program Integrity at CMS; Jim Frogue, founder of the government relations firm FrogueClark; Doug Porter, Washington State Medicaid director; and Bill Hazel, secretary of the Virginia Department of Health and Human Resources. Glen Schuster, chief technology officer of the Centene Corporation and Ed Howard of the Alliance co-moderated.


 Peter Budetti, CMS Center for Program Integrity, Speaker
 Jim Frogue, FrogueClark, Speaker
 Doug Porter, Washington State Department of Social and Health Services, Speaker
 Bill Hazel, Virginia Department of Health and Human Resources, Speaker
 Glen Schuster, Centene Corporation, Moderator
(Click on the camera icon to see a video of the speaker's presentation.)

Transcript, Event Summary and/or Webcast and Podcast

Transcript: Transcript (Adobe Acrobat PDF), 3/5/2012
Event Summary: Event Summary (Adobe Acrobat PDF), 3/5/2012
Full Webcast/Podcast: Program Integrity: How Much Money Can Combating Health Care Fraud and Abuse Save?

The full webcast and podcast for this briefing, as well as videos of individual speakers' presentations, are provided by Kaiser Family Foundation.

Speaker Presentations

Peter Budetti's Presentation (Adobe Acrobat PDF), 3/5/2012
Jim Frogue's Presentation (PowerPoint), 3/5/2012
Doug Porter's Presentation (PowerPoint), 3/5/2012
Bill Hazel's Presentation (PowerPoint), 3/5/2012
Glen Schuster's Presentation (PowerPoint), 3/5/2012

(If you want to download one or more slides from these presentations, contact us at info@allhealth or click here for instructions.)

Source Materials

Agenda (Adobe Acrobat PDF), , 3/5/2012
Materials List (Adobe Acrobat PDF), , 3/5/2012
Source List (Adobe Acrobat PDF), , 3/5/2012
- Contact Information of Experts on Fraud and Abuse
Speaker Biographies (Adobe Acrobat PDF), , 3/5/2012
Event Summary (Adobe Acrobat PDF), , 3/5/2012

Offsite Materials (briefing documents saved on other websites)

Physician Medical Identity Theft, Journal of the American Medical Association, 2/1/2012
- Shantanu Agrawal and Peter Budetti
Waste and Abuse in Government Health Care, Centers for Medicare and Medicaid Services, 4/5/2011
- Peter Budetti and Deborah Taylor
Combating Fraud, Waste and Abuse in Health Care, Center for Medicare Advocacy, 2/13/2012
Health Reform Should Begin with Ending Fraud, Real Clear Politics, 9/15/2009
- Jim Frogue and Tom Coburn
Gingrich and Frogue: Congress Must Eliminate Fraud, Roll Call, 6/4/2009
- Newt Gingrich and Jim Frogue
Health Care Fraud Prevention and Enforcement Efforts Result in Record-Breaking Recoveries Totaling Nearly $4.1 Billion, U.S. Department of Health & Human Services, 2/14/2012
Whistle Blowers Key in Health Care Fraud Fight , USA Today, 2/23/2012
- Kelly Kennedy
Medicare Fraud, Waste, and Abuse – Challenges and Strategies for Preventing Improper Payments - highlights, United States Government Accountability Office, 6/15/2010
- Kathleen M. King
A 'Smart' Approach to Medicare Reform, The Hill’s Congress Blog, 11/2/2011
- Mark Kirk and Ron Wyden
Medical Specialties to Develop List of Unnecessary Procedures, American Medical News, 1/9/2012
- Carolyne Krupa
ACOs and the Enforcement of Fraud, Abuse, and Antitrust Laws, New England Journal of Medicine, 1/13/2011
- Robert F Leibenluft
Medicare Fraud & Abuse: Prevention, Detection, and Reporting, Centers for Medicare & Medicaid Services, 10/1/2011
Record Number of Federal Criminal Health Care Fraud Prosecutions Filed in FY 2011, TRAC, 12/14/2011
How Much Fraud and Abuse Is There in U.S. Health Care, The New York Times, 3/5/2012
- Uwe E. Reinhardt
How to Stop Paying Bad Medicare and Medicaid Claims, Center for American Progress, 4/1/2011
- Marsha Simon
Slow Start for Medicare’s New Fraud-Busting Computer Disappoints Lawmakers, The Washington Post, 2/23/2012
Educating Physicians to Prevent Fraud, Waste, and Abuse, The New England Journal of Medicine, 1/13/2011
- Julie K Taitsman
Avoiding Medicare and Medicaid Fraud and Abuse, Office of Inspector General - Department of Health and Human Services , 3/5/2012
Medicare Program Integrity: Activities to Protect Medicare from Payment Errors, Fraud, and Abuse , Congressional Research Service, 7/29/2011
- Cliff Binder
Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2011, The Department of Health and Human Services and the Department of Justice, 2/1/2012
Medicare Advantage Organizations’ Identification of Potential Fraud and Abuse, Department of Health and Human Services Office of Inspector General, 2/1/2012
- Daniel Levinson
States Continue to Feel Recession’s Impact, Center on Budget and Policy Priorities, 2/27/2012
- Elizabeth McNichol and Phil Olif and Nicholas Johnson
Options for Enhancing Fraud and Abuse Deterrence in the Virginia Medicaid Program, Commonwealth of Virginia – Department of Medical Assistance Services, 12/1/2010
Research Brief: Insurers’ Efforts to Prevent Health Care Fraud, America’s Health Insurance Plans, Center for Policy and Research, 1/1/2011
Health Care Fraud and Abuse Laws Affecting Medicare and Medicaid: An Overview, Congressional Research Service, 8/10/2012
- Jennifer Staman


Peter Budetti, CMS deputy administrator for program integrity, discussed CMS efforts to combat fraud and abuse at the March 5 briefing cosponsored by the Centene Corporation. (12 min.)


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