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Patricia O'Connell
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Health Care Practice Co-Chair Kirk Nahra Talks Fraud Prevention with Health Plan Week

Health Plan Week
April 25, 2011

Wiley Rein’s Kirk Nahra, co-chair of the Health Care Practice, was quoted commenting on a provision in the health care reform law and its potential impact on fraud prevention efforts. Health insurers have become more proactive in seeking out fraud and abuse but experts worry that the medical loss ratio (MLR) provision of the reform law could hamper their efforts. Industry experts say that the MLR rule focuses on Medicare and Medicaid fraud, but ignores fraud in the private sector, and also categorizes fraud prevention as an administrative expense, which can be compensated by any money recovered. This could create disincentives for fraud prevention. “You could argue that while on one hand the law gave the government a million new tools to fight fraud within government programs, the MLR rules are written in a way that create disincentives for doing anti-fraud activity on the private side,” Mr. Nahra said. “The MLR rule certainly hasn’t helped, and we can debate whether it’s neutral,” he added.

Some argue that it is too soon tell if the MLR provision will impede anti-fraud efforts, as the return on investment from fraud investigations is usually high. Mr. Nahra, however, says that “recovering money that shouldn’t have been paid in the first place shouldn’t be seen as a return on investment.”