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Calling anti-fraud and abuse efforts "a top personal priority" for the second term of the Clinton administration, HHS Secretary Donna E. Shalala today announced a new and expanded phase of "Operation Restore Trust," the special initiative that President Clinton launched in May 1995.

In its first two years as a demonstration project, "Operation Restore Trust" has identified almost $188 million owed to the federal government, Secretary Shalala announced. This constitutes a return of more than $23 for every $1 spent on the project. Now, Shalala said, lessons learned in the demonstration phase will be incorporated into efforts throughout HHS to combat fraud and abuse in Medicare and Medicaid.

"Operation Restore Trust has shown us how to move faster and smarter in rooting out fraud and abuse in health care," Shalala said. "This is a model that works. Now it's time to take what we've learned and use it broadly and aggressively."

Wider use of "Restore Trust" techniques is one of several elements in the administration's broadening attack on fraud and abuse in health care. President Clinton announced a number of other new initiatives March 25. Total HHS spending for anti-fraud, waste and abuse efforts in Medicare and Medicaid is $599 million in FY 1997, up from $452 million five years earlier.

The "Operation Restore Trust" demonstration included several new anti-fraud and abuse approaches. The initial ORT demonstration project focused on five states, which include more than a third of all Medicare and Medicaid beneficiaries: California, Florida, New York, Texas and Illinois.

In the five states, ORT brought together teams to target efforts on three high-growth program areas of Medicare and Medicaid: home health agencies, nursing homes, and durable medical equipment suppliers.

During the next two years, the ORT expansion will include new geographic areas of concentration as well as several new specific anti-fraud and abuse targets. Over the longer term, techniques developed by ORT will be applied in all 50 states, and will be applied throughout Medicare and Medicaid program areas.

New states where ORT efforts will initially be focused are Arizona, Colorado, Georgia, Louisiana, Massachusetts, Missouri, New Jersey, Ohio, Pennsylvania, Tennessee, Virginia and Washington.

In addition, Secretary Shalala announced today that the HHS-TIPS hotline is being improved, and that HHS agencies are working with other organizations, including the American Association of Retired Persons, to make the hotline better known and more user-friendly.

Under ORT, a hotline was established (1-800-HHS-TIPS) for the public to directly report problems that might indicate fraud, abuse or waste. Since the hotline was activated in June 1995, it has received over 13,000 complaints related to HHS programs.

"Beneficiaries and honest health care providers can be some of our most important allies in fighting fraud," Secretary Shalala said. "We want them to know how they can reach us and how they can help."

"Operation Restore Trust" has increased outreach to beneficiaries and providers to encourage their help in identifying problems. For example, a special office was established in Miami providing outreach to the local community to alert the public and local businesses to health care fraud schemes.

Other new approaches which have been demonstrated under the ORT initiative include:

• Use of sophisticated statistical methods to identify providers for investigations and audit
  
  
• Use of interdisciplinary teams to review individual facilities with unusually high Medicare reimbursement rates. Reviewers look both for facility-specific evidence and for indications of systemic problems
  
  
• Increased emphasis on concerted planning and conducting of investigations with the Department of Justice and other law enforcement agencies
  
  
• Training and empowering state and local aging organizations and ombudsmen to detect and report fraud in nursing homes and in other settings
  
  
• Use of state survey officials who regularly monitor care in home health agencies and nursing homes to help identify inappropriate and fraudulent billing Program savings identified from ORT's two-year demonstration phase currently total $187.5 million in restitutions, fines, settlements and other identified overpayments.
  

This includes $67.3 million from criminal restitutions and fines; $72.8 million as a result of civil judgments, settlements and fines; and $47.4 million as a result of services inappropriately billed or medically unnecessary services rendered. During the two-year period, total spending on "Operation Restore Trust" was $7.9 million.

So far, 74 criminal convictions and 58 civil actions are attributable to ORT. In addition, 218 fraudulent health care providers have been excluded from Medicare and Medicaid. Currently, another 210 cases stemming from the two-year ORT demonstration are being investigated.

In addition, studies conducted under the auspices of "Operation Restore Trust" have provided new insights and evidence of program vulnerabilities and actions that can be taken to reduce vulnerability.

"Operation Restore Trust" is a joint effort within HHS involving the Office of the Inspector General, the Health Care Financing Administration and the Administration on Aging.