www.nhcaa.orgwww.nhcaa.org ©2013 National Health Care Anti-Fraud Association

A PrivAte-Public PArtnershiP AgAinst heAlth cAre FrAud

1201 NEW YORK AVENUE, NW • SUITE 1120 • WASHINGTON, DC 20005

• Maintaining a strong private-public partnership in combating health care fraud and abuse

• Providing unparalleled learning opportunities related to combating health care fraud and abuse

• Providing opportunities for private and public-sector information sharing related to health care fraud and abuse

• serving as a national resource for health care anti-fraud information and professional assistance to government, industry and media

• recognizing and advancing professional specialization in the detection, investigation and/or prosecution of health care fraud and abuse through accreditation of health care anti-fraud professionals

WHO WE AREFounded in 1985 by several private health insurers together with federal and stategovernmentofficials,theNationalHealthCareAnti-FraudAssociationistheonlynationalorganizationfocusedexclusivelyonthefightagainsthealthcarefraud. We are a private-public partnership — our members comprise the nation’s most prominent health insurers and those public-sector law enforcement and regulatory agencies having jurisdiction over health care fraud.

Our Mission is to protect and serve the public interest by increasing awareness and improving the detection, investigation, civil and criminal prosecution, and prevention of health care fraud and abuse.

nhcAA pursues that Mission by:

the national health care Anti-Fraud Association is the onlynationalorganizationfocusedexclusivelyonthefightagainst health care fraud.“

“PARTNERSHIPnhcAA is a private-public partnership against health care fraud. Providing a venue where private insurers and government entities can work together to address this serious problem has always been central to nhcAA’s Mission and success. the simple principle that we can accomplish more together than we can separately has been the foundation of nhcAA since our inception in 1985.

GLOBAL HEALTH CARE ANTI-FRAUD NETWORK nhcAA and our Members play an active role in international health care fraud issues. the global health care Fraud network (ghcAn) was founded in 2011 by nhcAA and our international partners including, the canadian health care Anti-fraud Association, the european healthcare Fraud & corruption network, the healthcare Forensic Management unit, and the health insurance counter Fraud group.

the mission of ghcAn is to promote partnerships and communications among international organizations in order to reduce and eliminate health care fraud around the world. ghcAn aims to further this mission by:

• raising awareness internationally about the issue of health care fraud

• gathering and sharing information on the trends, issues, facts and statistics relating to the problem

• Working cooperatively to improve international standards of practice around fraud prevention, detection, investigation and prosecution

• developing joint education and training programs designed to prepare and provide continuing education for the world’s health care anti-fraud professionals

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• billing for services and products that were never rendered

• billing for more expensive services or procedures than were actually provided or performed, commonly known as “upcoding”

• Performing medically unnecessary services solely for the purpose of generating insurance payments

• Misrepresenting non-covered treatments as medically necessary covered treatments for the purpose of obtaining insurance payments

• Medical identity theft

• Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary

• billing each step of a procedure as if it were a separate procedure, commonly known as “unbundling”

• Accepting kickbacks for patient referrals

• Failing to provide necessary services pre-paid under a health plan

• Prescription drug diversion and misuse

health care Fraud is a serious problem costing tens of billions of dollars every year and it directly undermines the quality of health care.“

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Insummary,healthcarefraudencompassesabroadrangeofillegalactivities.Unchecked,itcanbeextremelyprofitableforthose who perpetrate it.

WHY SHOULD WE CARE?the united states spends nearly $3 trillion on health care every year—equating to nearly 18 percent of our nation’s gross domestic Product(GDP).*Whilenooneknowsforsurewhatpercentageofthatamountislosttofraud,NHCAAisconfidentinestimatingthatthefinanciallossesduetohealthcarefraudareinthetensofbillionsofdollarseachyear.

this loss directly impacts patients, taxpayers, and the government, resulting in higher health care costs, insurance premiums and taxes foreveryone.However,financiallossesareonlypartofthestory.Sadly,healthcarefraudoftenharmspatientswhoareexploitedandsubjected to unnecessary or unsafe medical procedures or who may be the victims of identity theft. in fact, medical identity theft is not a crime limited to patients—many health care providers also are the victims of identity theft, often resulting in serious damage to their professional reputations.

*Source:CenterforMedicareandMedicaidServices,OfficeoftheActuary

WHAT IS HEALTH CARE FRAUD?broadly speaking, health care fraud is the use of deliberate deception designed to obtain illegal gain from our nation’s health care system. Most often, health care fraud involves the deliberate submitting of false insurance claims with the goal of receiving money or other benefits.Itisaseriousoffensethatcanbecommittedagainstindividuals,commercialhealthinsuranceplans,ortax-fundedpublic health programs such as Medicare and Medicaid.

health care fraud is a serious problem costing tens of billions of dollars every year. it also directly undermines the quality of health care. Perpetrators of health care fraud can include organized crime groups, dishonest health care providers and suppliers, and even patients.

health care fraud can be an exceptionally complex crime. consider this—billions of health care claims are generated in the united states every year in public programs like Medicare and Medicaid and through private insurance. For those looking to commit fraud, the enormous volume of claims for payment for medical services and supplies delivered to the American people annually presents an enticing opportunity.

common types of health care fraud include:

ANTI-FRAUD INITIATIvEScreating opportunities for nhcAA member organizations and law enforcement liaisons to share anti-fraud information is fundamental to our mission. Perpetrators of health care fraud do not discriminate between payers—if false claims are being submitted to one insurer, it’s likely that other insurers or public programs are also being exploited. therefore, the timely sharing of anti-fraud information among commercial health insurersandfederalandstatelawenforcementandregulatoryagenciesiscriticaltobeingabletowageaunifiedandultimatelysuccessfulbattleagainst health care fraud. nhcAA enables information sharing using several approaches:

SIRIS (SPECIAL INVESTIGATION RESOURCE AND INTELLIGENCE SYSTEM)SIRIS is a web-based database powered by lexisnexis that allows authorized users to effectively share critical information about suspected fraudulent activity throughout the country.

CASE DISCUSSION ROUNDTABLE MEETINGSnhcAA hosts a number of meetings throughout the year, giving our member organizations and law enforcement liaisons the opportunity to network and discussgeneralanti-fraudissuesandspecificinvestigations,aswellasshareadviceandinformationonemergingfraudschemesandtrends.

ANTI-FRAUD INITIATIVE E-NEWSLETTERSnhcAA offers two members-only information-sharing newsletters – Inside SIRIS is a monthly publication containing statistics and analysis of cases and schemes entered into siris. The Compass contains trending investigative information from siris and also includes intelligence gathered from law enforcement and private company siu managers providing the latest information on trends and schemes across the nation.

FRAUD ALERTSPeriodically,NHCAAissueselectronicfraudalertstomemberswhensignificantanti-fraud information comes to our attention which is of general membership interest and which needs to be disseminated quickly.

CASE-SPECIFIC REQUESTS FOR INVESTIGATION ASSISTANCE (RIA) FROM LAW ENFORCEMENTThisuniqueinformation-sharingtoolallowslawenforcementagenciesandprosecutorstosubmitrequestsconcerningspecificfraudcasestoourprivateinsurermembers.Thisprocessisquickandefficient,facilitatingcasedevelopmentandidentificationofadditionalvictimsandperpetratorsoffraud.

PEER EXPERIENCE RESOURCE CENTER (PERC)ThecollectivefraudfightingexperienceofNHCAA’sMemberOrganizationsisinvaluable.PERCoffersmemberstheopportunitytoseekinputfromtheirindustry peers about unique, pressing or particularly challenging operational or policy-related issues, and to gather information on best practices.

ANTI-FRAUD INTEREST GROUPSWhen critical fraud issues arise in a particular geographic location or in a specialized service area, special interest groups are established which then meet and share information to address the challenge.

BEHAVIORAL HEALTH CARE FRAUD INTEREST GROUP the behavioral health interest group provides a forum for nhcAA members to discuss the unique characteristics of behavioral health care fraud while providing education in this particular topic area.

DENTAL FRAUD INTEREST GROUP the dental Fraud interest group brings together perspectives of medical advisors and investigative professionals to discuss issues related to dental fraud cases and schemes.

GLOBAL HEALTH CARE FRAUD INTEREST GROUPcombating health care fraud is not only a challenge in the united states, but also throughout the world. nhcAA’s global health care Fraud interest group is designed to bring together member organizations and law enforcement liaisons providing a forum to discuss topics related to global health care fraud.

MEDICAID FRAUD INTEREST GROUPTheMedicaidFraudInterestGroupstrengthenscooperationbetweenstatesandhealthplansinfightingMedicaidfraud,whilealsoprovidinginsight on investigative cases, schemes and issues related to fraud in this key federal & state program.

MEDICAL DIRECTOR’S ADVISORY GROUPthe Medical director’s Advisory group provides examination and discussion of key issues and challenging topics related to medical policy and appropriate utilization of medical services as they relate to health care fraud.

PRESCRIPTION DRUG FRAUD INTEREST GROUPthe Prescription drug Fraud interest group discusses key issues related to prescription fraud and other pharmacy-related topics. the interest group provides knowledge and guidance to nhcAA on prescription drug fraud issues and topics.

EDUCATION & TRAININGeducation and training has always been integral to the nhcAA mission. nhcAA offers unparalleled learning opportunities through the nhcAA institute for health care Fraud Prevention. institute programs provide our members with the knowledge to address emerging health care fraud trends and to understand the new technologies being developed to detect and prevent them. Our education programs are diverse and timely, enabling us to meet the shifting needs of the anti-fraud professional with a steady focus on increasing knowledge and building skills.

NATIONAL EDUCATION & TRAINING SERIES (NETS)each year the nhcAA institute plans a full calendar of in-person and online training programs. the In-person NETS are held throughout the united states and provide an in-depth look at current health care fraud schemes and investigative skills, incorporating hands-on learning, roundtables and case studies. in-person nets also provide invaluable networking opportunities. the Online NETS are web-based seminars that are cost-effective alternatives to in-person meetings and ideal for unit-wide training. each webinar is designed to focusonaspecificskillorscheme,providingknowledgethatcanbeappliedimmediately.

DISTANCE LEARNINGnhcAA has developed e-learning compliance and training programs to provide anti-fraud education in an effective, convenient and economical format. Programs focus on building investigative skills, as well as general fraud awareness training for physicians, pharmacies and other health care professionals.

AUDIO CONFERENCESOur audio conference series enables nhcAA to reach members quickly and directly about critical health care fraud issues and schemes. the format allows NHCAAtobeflexibleandresponsivetoemergingtrendsandprovidesmembersa convenient way to earn continuing professional education (cPe) credits.

ANNUAL TRAINING CONFERENCEthe Annual training conference (Atc) is recognized as the single-most important health care anti-fraud national training event, spotlighting emerging schemes and best practices, and bringing together the industry’s leading minds to share information on methods to detect, investigate, prosecute and prevent health care fraud. the expanding Anti-Fraud expo continues to be the primary source for identifying new products and services in the health care anti-fraud marketplace. each year the Atc draws more than 1,200 health care anti-fraud and law enforcement professionals who gather to network, exchange ideas, and attend the several dozen workshops offered on all aspects of health care fraud.

For more information about the Atc, visit www.nhcaa.org/ATC.

ACCREDITED HEALTH CARE FRAUD INVESTIGATOR (AHFI®) DESIGNATIONestablished in 2002, AhFi® is a unique professional designation granted by nhcAA to individuals who demonstrate unwavering dedicationtofightinghealthcarefraud.SuccessfulAHFI®candidatesmustpassanexaminationandmeetstrictqualificationsrelatingto professional experience, specialized training, formal education, and demonstrated knowledge in the detection, investigation, and prosecution of health care fraud. An AhFi®designationsignifiesthehighestlevelofprofessionalaccomplishmentwithinthehealthcareanti-fraudfield.

Our Mission to protect the public interest is the driving force behind our efforts in the government affairs arena.“

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GOvERNMENT AFFAIRSOur Mission to protect the public interest is the driving force behind our efforts in the government affairs arena. nhcAA regularly offers its perspective as a subject matter expert on legislative and regulatory developments that could impact health care anti-fraud efforts. GroupssuchastheU.S.GovernmentAccountabilityOffice(GAO),theNationalAssociationofInsuranceCommissioners(NAIC),andcongressional staff have sought our insight on the health care fraud issue. We provide our views publicly through white papers, comment letters, testimony and our media outreach program. Additionally, nhcAA government Affairs works to cultivate strategic partnerships with key public interest groups and other professional associations.

We also track and report on pertinent legislative and regulatory activities at the state and federal levels, and maintain a searchable catalog accessiblebymembersofstatutesandregulationsrelevanttotheanti-fraudfield.

nhcAA board members and executive staff are active on the public policy stage – receiving invitations to appear and testify at public meetings regarding health care fraud. We work closely with many government agencies, including the departments of Justice and health and human services to improve the level of anti-fraud cooperation between the private and public sectors. nhcAA is also an active participant on the healthcare Fraud Prevention Partnership (hFPP), serving on the executive board, the data Analytics and review committee (dArc) and the information-sharing committee (isc).

The LenSnhcAA’s government affairs e-newsletter, The Lens, keeps nhcAA members regularly apprised of news and developments at the federal andstatelevelswhichcouldimpactanti-fraudeffortsorbeofinteresttothehealthcarefraudfightingprofession.

HEALTH CARE ANTI-FRAUD RESOURCESnhcAA is the primary source for current, accurate and authoritative information about health care fraud. some key nhcAA resources include:

The BeACOnnhcAA’s monthly e-newsletter providing members with timely information on educational programs, membership news, new products and membership services, accreditation developments, and anti-fraud initiatives.

THE NHCAA ANTI-FRAUD MANAGEMENT SURVEYTheindustry’sbenchmarkingtoolforassessingthestructure,staffing,funding,operationandresultsofcommercialhealthinsurance anti-fraud investigative units.

nhCAA neWS BRIeFA weekly email alert service providing highlights of the most noteworthy health care fraud news including industry updates, judicial proceedings and legislative developments.

NHCAA EDUCATION & TRAINING UPDATE A monthly e-newsletter providing highlights of recent training programs, alerts on upcoming education & training programs, and interesting fraudfightingtips.

NHCAA CAREER CONNECTIONthe only online career center dedicated to the health care anti-fraud industry, enabling employers and health care anti-fraud professionals toconnect.Insurers,governmentagenciesandcompaniesofferingfraudsolutionshavepostedhundredsofhealthcarefraud-fightingjobs since career connection’s launch in 2005.

NHCAA WEBSITE—WWW.NHCAA.ORG streamlined, dynamic, user-friendly, and full of useful services and information for health care anti-fraud professionals, as well as health care consumers.

NHCAA MEMBERSHIPnhcAA offers membership categories for health insurers, government program integrity contractors, governmental entities, and other companiesandorganizations,aswellasindividuals,whowanttojoinusinthefightagainsthealthcarefraud.

MEMBERSHIP CATEGORIESMEMBER ORGANIzATIONScommercial health insurers, managed care organizations, companies thatself-insureorself-administertheirownhealthbenefits,third-partyadministrators, and government program integrity contractors.

LAW ENFORCEMENT LIAISONSPublic sector agencies, including law enforcement and prosecutorial or regulatory agencies, responsible for the detection, investigation, civil and criminal prosecution or prevention of health care fraud.

AFFILIATE MEMBERSinsurance companies other than health insurers that provide reimbursement of health care expenses through workers’ compensation, disability or other property and casualty insurance products where medical fraud may occur.

SUPPORTING MEMBERSOrganizations other than insurance companies that support the nhcAA Mission to combat health care fraud and adhere to principles and purposes compatible with those of nhcAA. supporting Members are most often companies that provide services and solutions toNHCAAMemberOrganizationsandAffiliateMembers.

INDIVIDUAL MEMBERSPersons who occupy managerial, supervisory or professional positions in organizations eligible for membership as Member Organizations,LawEnforcementLiaisons,AffiliateMembers,orSupportingMembers.

TolearnmoreaboutNHCAAandhowmembershipcanbenefityouoryourorganization,pleasecontactusat202.659.5955, email us at nhcaa@nhcaa.org or visit our website at www.nhcaa.org.

www.nhcaa.org ©2013 National Health Care Anti-Fraud Association

1201 NEW YORK AVENUE, NW • SUITE 1120 • WASHINGTON, DC 20005

www.nhcaa.org ©2013 National Health Care Anti-Fraud Association

NATIONAL HEALTH CARE ANTI-FRAUD ASSOCIATIONPhone: 202.659.5955Fax: 202.785.6764Email: nhcaa@nhcaa.org Web: www.nhcaa.org

1201 NEW YORK AVENUE, NW • SUITE 1120 • WASHINGTON, DC 20005