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By William Hayes, managing editor, Pennsylvania CPA Journal

The health care market is constantly evolving, influenced by a multitude of factors. How is the government using data to track fraud cases? What is the relevance today of the Affordable Care Act? How will blockchain technology affect the health care system? These are just some of the questions that need answers. Joanne M. Judge, CPA, JD, shareholder and cochair of the health law department at Stevens & Lee in Reading, Pa., led a session at the Dec. 4-5, 2019, PICPA Insurance Conference in Malvern, Pa. I met with her to preview her session and maybe find a few answers.

How is the government using data analytics to identify potential fraud cases?

In June 2016, the U.S. Department of Health and Human Services, Office of Inspector General, reported finding over 500 home health agencies and 4,500 physicians to be outliers for multiple characteristics commonly found in OIG-investigated cases of home health fraud. Further, the OIG identified 27 geographic areas in 12 states as hotspots for characteristics commonly exhibited in OIG-investigated cases of home health fraud. Specifically, the OIG identified five characteristics common to home health agency (HHA) fraud cases:

• High percentage of episodes in which the beneficiary had no recent visits with the supervising physician
• High percentage of episodes that were not preceded by a hospital or nursing home stay
• High percentage of episodes with a primary diagnosis of diabetes or hypertension
• High percentage of beneficiaries with claims from multiple HHAs
• High percentage of beneficiaries with multiple home health readmissions in a short period of time

Based upon a review of millions of claims, the OIG identified HHAs and supervising physicians that were statistical outliers with regard to the above characteristics when compared to their peers nationally. The OIG used a similar outlier approach when identifying the so-called hotspots.

Does the Affordable Care Act (ACA) still have relevance as we move into 2020?

Nine years after the ACA’s passage, Americans remain ambivalent about the law. Residents of the 34 states and the District of Columbia that expanded Medicaid under the law are more likely to say the law helped their family than respondents living in the 17 states that didn’t expand Medicaid. The administration’s new regulations allowing longer terms for short-term, limited-duration insurance, which is exempt from many ACA consumer protections, will create opportunities for payers selling and supporting these products in 2019, the first full year they will be sold under the new rules. The administration’s actions toward the ACA have shifted power to the states, which means the fates of many providers and payers depend on decisions made by state lawmakers and bureaucrats.

Is the rise of blockchain affecting the health care industry?

Blockchain is gaining traction as a tool that could help solve some of the health care industry's age-old problems that have resulted in wasteful spending and higher costs. Once reluctant competitors are joining forces to find out just what the technology can do, and in the process, they are developing new transparent business models. Blockchain has potential to help health care providers and payers bridge traditional data silos, dramatically increase efficiencies, keep health care data secure, and streamline patients' access to medical data. By offering trusted, seamless, and secure transfer of information, blockchain has the potential to reshape the health care industry information exchange. 

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