DOJ to put private payers on regional task forces
Expect more aggressive fraud enforcement in the wake of new guidelines issued by Attorney General Janet Reno.
The guidelines create a formal structure for cooperation between the Justice Department and private insurers. This marks a sea change for insurers who were never sure how much cooperation they could expect from each individual US Attorney, says Bill Mahan, executive director of the National Healthcare Anti-Fraud Association, which represents the fraud units of insurers and HMOs. For example, a regional fraud task force run by DOJ might eschew private payer fraud in favor of concentrating on Medicare and Medicaid fraud.
Now the government will put insurers on the regional task forces. More important, the Justice Department will appoint "information exchange coordinators," and expects insurers to do the same. DOJ wants insurers to turn over information on health fraud, as well as any useful resources that private fraud control units use.
In return, the Department of Justice pledges to turn over information on specific frauds to the particular insurers affected by those crimes, as long as the distribution is "practicable, permitted by law, and will not jeopardize ongoing law enforcement investigations."
More specifically, the department will disseminate public information such as settlements and indictments. In addition, there will be periodic newsletters that will discuss enforcement actions, as well as copies of reports submitted to the new Healthcare Integrity and Protection Data Bank.
As for the trickier matter of non-public information that the government uncovers, DOJ says it will try to provide what data it can. If health plans alert investigators to fraud committed by a provider, DOJ says it will try to keep the insurer abreast of the scope of the fraud and the outcome of the investigation.
It also promises to keep confidential the sources of the insurer’s information. That will soothe an insurer’s worst nightmare, says Mahan: That it passes on information on a fraud scheme, only to see the local US Attorney lay down indictments just for Medicare and Medicaid, and then collect a big settlement that doesn’t recoup money lost by the insurer.
Now DOJ says it will try to provide information that will let insurers get restitution, including money and property seized by the government. And if a private insurer is sued for turning information over to federal investigators, the Justice Department will provide affidavits defending the insurer’s action, says Mahan.
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