ders to do what's right:oeducational review; Aforgive@ past transgressions -- declare past transgressions Aoff the table@ and let organizations look forwardoengage providers in policing their own Initiate Administrative Law Judge (ALJ) reform:ochange regulations to reduce improper reversals Detection Foster beneficiary involvement:- help beneficiaries to keep track of the services they receive by requiring physicians to provide a detailed receipt at the time of service (Aimmunization record@ concept) Develop individual, unique provider number:- critical in order to detect multiple billing Develop and use software:- needs to be improvements to catch aberrancies -- look for large increases in expenditures and volume over short periods of time or in small geographic areas; uniform data an software to address scams and abusive actions in Areal time@ and across geographic and service areas- Use more computer edits: Medicaid experience is that Medicaid is getting taken for things that simple edits would have prevented Develop and use normative standards Coordinate best practices with partners:- both private and public health insurers should be able to share information Conduct more data analysis:- regular mining of data to look for trends, profile providers, Aspikes@ in billing Reconcile Privacy Act issues:- may need to re-examine the Privacy Act, particularly related to data sharing and information sharing targeted at preventing and detecting fraud and abuse Enforcement Improve and evolve enforcement efforts and tools:- implement mechanisms for private entities to be able to take fraudulent providers or Abad actors@ to court and supplement the federal government- provide fraud training for beneficiaries and providers- sentencing guidelines need to be re-evaluated: increase punishment for violations -- longer jail sentences, higher monetary penalties; punishment should be equal to the crime- change approach to prosecuting white collar crime...
