Reform helps spur more Medicaid fraud busts

There’s good and bad news for the health care reforms passed last year (and which Republicans hope to decimate this year).

First the good: Thanks to the law, a record amount of money was recovered from fraudulent Medicare claims last year.

The Department of Health and Human Services recovered a total of $4 billion last year. Now some of that would have been recovered anyway but the reform act increased enforcement dollar and helped HHS crack down even more.

The return on the investment? $4.90 for every $1 spent, according to HHS.

The law created more strike force task teams that focused on Medicare fraud throughout the nation. In a partnership with the Department of Justice, the task forces were able to prosecute more cases, and reclaim a record amount of money. The task forces cracked down on insurance companies, doctors, hospitals, clinics, pharmacies and medical device companies that filed false claims for Medicare and Medicaid reimbursements.

That resulted in 140 indictments of 284 defendants who collectively billed the Medicare program more than $590 million. There were 217 guilty pleas and 19 jury trials. About 146 people went to prison last year for Medicare fraud crimes. They will serve an average of 40 months.

The $4 billion was returned to the Medicare Health Insurance Trust Fund, the Treasury and other government departments last year.

HHS also had a record year for recoveries in civil health care matters under the false claims act — more than $2.5 billion, the largest in history for the Department of Justice.

This year, the reforms give HHS even more money and more authority. The law authorizes an additional $350 million for investigative activities. HHS is already using tools authorized by the reform act — enhanced screenings and re-enrollment requirements, increased data-sharing across government, expanded overpayment recovery efforts and greater oversight of private insurance abuses.

In addition, the law provides authority to stop payments when the government is investigating fraud cases against an insurance company.

OK, so now for the bad news.

Electronic health records don’t really improve quality of health care most patients receive, according to a Stanford University study.

While the Obama reforms mandated use of electronic records by 2014, and industry experts tout them as a way to ensure safety and quality of care, Stanford’s three-year study found electronic records and associated devices just don’t do much to improve quality.

“There’s a lot of enthusiasm and money being invested in electronic health records,” said Dr. Randall Stafford, a Stanford researcher who conducted the research project. “(But) it’s an unproven proposition. The federal government’s investment is because (they think) it will improve the quality of care, but that’s not based on evidence. That’s a presumption.”

Stafford analyzed data from nearly 250,000 patient visits from 2005 to 2007. He looked at whether computerized, clinical decision-support tools in electronic health records (EHRs) improved the quality of care.

“(There was) no consistent association between EHRs and better quality,” the report said. “These results raise concerns about the ability of health information technology to fundamentally alter care quality.”

Local hospitals have spent millions turning to electronic record-keeping, and the state launched a multimillion-dollar effort two years ago to have all the electronic records in the state linked together.

Despite his findings, Stafford still believes electronic records are necessary in health care. They’re used in every other industry, he said, from supermarkets to automobiles to banking. Health care has lagged behind, and simply needs time to catch up.

The problem isn’t the records themselves, or the expense to install them, Stafford said. It’s not even the conflicting software that currently prohibits linking to other doctors and hospitals. It’s the lack of training about how to use the records. Possibly, doctors aren’t making full use of them.

Stafford believes that the government shouldn’t just throw $19 billion — the amount set aside to subsidize industry moves toward electronic record keeping — at doctors and hospitals.

“Government spending and research should focus more on the issues of quality and equity, rather than just broadly endorsing information technology as categorically good,” he said.

Amy Gillentine can be reached at 719-329-5205 or at amy.gillentine@csbj.com. Friend her on Facebook.