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Fraud, Waste and Abuse (FWA)

Summer 2016 Bulletin

Welcome to the first bulletin from Memorial Hermann Health Solutions, Inc. on Fraud, Waste and Abuse (FWA). As an insurance company and payor, we monitor current trends in Medicare, Medicaid and Insurance fraud. The purpose of this communication is to introduce you to our FWA program and why we do what we do. Future communications will contain information about the latest trends and recent cases. Also, look for our FWA articles in your upcoming Provider Newsletter.

Like other insurance companies, we are continuously monitoring and auditing our claims in line with national trends. You may receive a letter from us requesting medical records or an explanation for a specific billing practice, so please respond within the requested timeframe. We receive federal and state funding so we must properly act to maintain our contractual obligations with the government, including diligently investigating any irregularities in claims. Examples of irregularities may include spikes in billing, outliers or abnormal billing patterns. Receiving a letter is not an accusation, it's simply a part of our oversight because an anomaly may have been detected.

In June an unprecedented nationwide sweep led by the Medicare Fraud Strike Force, resulted in criminal and civil charges against 301 individuals, including 61 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving approximately $900 million in false billings. This was a joint effort involving twenty-three state Medicaid Fraud Control Units, and the Department of Health Human Services (HHS).This coordinated takedown is the largest in history, both in terms of the number of defendants charged and loss amount.

The Medicare Fraud Strike Force is part of the Health Care Fraud Prevention & Enforcement Action Team (HEAT). It's a joint initiative announced in May 2009 between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws. The Strike Force operates in nine locations and since its inception in March 2007 has charged over 2,900 defendants who collectively have falsely billed the Medicare program for over $8.9 billion. Houston is one of the Medicare Fraud Strike Force’s location with Harris County being a top 5 HEAT county making this market a hotbed of healthcare fraud.

If you have any questions about Memorial Hermann Health Solutions, Inc.’s FWA program please feel free to call me directly at 713.338.6665.

Vivian A. Wozniak, J.D.
Regulatory Compliance and Fraud, Waste & Abuse

“National Health Care Fraud Takedown Results in Charges against 301 Individuals for Approximately $900 Million in False Billing, (2016), https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-charges-against-301-individuals-approximately-900 (updated June 23, 2016).

https://www.stopmedicarefraud.gov/aboutfraud/heattaskforce/