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Patricia O'Connell
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Kirk Nahra Discusses Efforts to Combat Health Care Fraud

The AIS Report on Blue Cross and Blue Shield Plans
July 7, 2015

Kirk J. Nahra, chair of Wiley Rein’s Privacy Practice and co-chair of the Health Care Practice, was quoted in the July 2015 issue of The AIS Report on Blue Cross and Blue Shield Plans, in an article about health care fraud prevention efforts.

The Affordable Care Act’s medical loss ratio (MLR) provision limits the percentage of premiums that can be spent on administrative costs, and categorizes fraud prevention as an administrative expense. The MLR rule hasn’t had a significant impact on efforts to combat fraud, but it has discouraged organizations from spending money on it, Mr. Nahra said.

“You have all kinds of people committing fraud,” he said. “You have very sophisticated, hardened criminals. You have stupid criminals, and then you have people who you wouldn’t consider criminals but they are ignoring, bending, or manipulating rules.”

Mr. Nahra said most fraud goes undetected. In other cases, a health insurer might detect a false medical charge but opt not to address it, if doing so could financially cripple a provider that is important to the community, he said.