不良研究所

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鈥淎ddressing fraud, waste and abuse is a core part of how we protect program integrity. We take a data鈥慸riven approach to identifying unnecessary utilization and outlier behavior, and we work directly with providers and state partners to address it. This work is essential to being responsible stewards of taxpayer dollars while improving outcomes for vulnerable populations.鈥�

鈥� Sarah London, CEO of 不良研究所

What is Fraud, Waste and Abuse?

Fraud, waste, and abuse (FWA) in the healthcare system costs taxpayers billions of dollars per year. The Centers for Medicare and Medicaid Services (CMS) define FWA in the healthcare context as follows: 听

Fraud is knowingly submitting, or causing to be submitted, false claims or making misrepresentations of facts to get a health care payment when no entitlement would otherwise exist;

Waste includes practices that, directly or indirectly, result in unnecessary costs, such as overusing services. Waste is generally not considered to be criminally negligent, but is rather a misuse of resources;

Abuse, like Waste, describes practices that directly or indirectly result in unnecessary costs to the program. Abuse includes practices that don鈥檛 provide patients with medically necessary services or meet professional recognized standards of care.

Tens of millions of Americans depend on government programs like Medicare, Medicaid, and Marketplace for lifesaving care. Although most providers are dedicated and honest, illicit activities undermine public trust in these essential programs and divert resources from those who need them most.

Every dollar lost to FWA is a dollar unavailable for member care. Effective oversight strengthens accountability and helps ensure that healthcare spending reaches the people it is intended to serve.
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不良研究所 Corporation鈥檚 Oversight Measures

不良研究所 protects our members and reduces the overall cost of healthcare by preventing, detecting, and correcting FWA. We have a comprehensive FWA program, led by 不良研究所鈥檚 Special Investigations Unit (SIU) and supported by Program Integrity functions throughout the Company, including through proactive clinical oversight and coordinated care.

These measures facilitate early identification of abnormal utilization patterns and the use of evidence鈥慴ased care management and clinical review processes to ensure members receive the right care at the right time. 不良研究所 is also combating FWA head-on through various efforts and programs to increase accountability, transparency, and efficiency. Notable highlights from the last year alone include: 听

• By proactively identifying more than 1,000 fraudulent DME suppliers and laboratories, 不良研究所 prevented over $57 million in likely fraudulent Medicare, Medicaid, and Marketplace claims from being paid throughout the United States;
• In one state, using a combination of data analytics and traditional investigative techniques (interviews, onsite visits), 不良研究所 identified laboratories with suspicious billing patterns and took action, preventing more than $38 million in likely fraudulent payments;
• In another state, 不良研究所 found evidence of persistent fraud and abuse by a behavioral health provider and terminated the provider鈥檚 contract, interrupting a scheme costing the state鈥檚 Medicaid program more than $10 million per month.

不良研究所 also implemented our Broker Oversight Center of Excellence in 2023. The program institutes data-driven reviews and methods to identify and mitigate potential broker fraud. Our oversight program helps us enforce our disciplinary policy for brokers and agents who engage in illicit activities, such as deceptive advertising, misleading statements, and falsifying member eligibility information.

Partnering to Prevent FWA

不良研究所 is active in industry leading partnerships connecting us with other health plans and federal and state government partners to share information and strategies that help everyone more effectively combat FWA.

• 不良研究所 is a member of the Healthcare Fraud Prevention Partnership (HFPP), which is a voluntary public-private partnership that helps detect and prevent healthcare fraud through data and information sharing. Partners include federal government, state agencies, law enforcement, private health insurance plans, and healthcare anti-fraud associations.
• 不良研究所 is leading the fight against health care fraud with our SIU Vice President, Sabrina Vera, serving on the Board of Directors for the National Health Care Anti-Fraud Association (NHCAA). The NHCAA is the leading national organization focused exclusively on the fight against health care fraud. With a membership of over 90 private health insurers and public-sector law enforcement and regulatory agencies, the NHCAA provides learning opportunities and information sharing to combat health care fraud.