Since the inception of Medicare Fraud Strike Force operations in March 2007, the Strike Force has obtained indictments of more than 460 individuals and organizations that collectively have falsely billed the Medicare program for more than one billion dollars. In addition to the fraud hotbeds in Los Angeles, Houston, Detroit and — the one that dwarfs all three of them combined — Miami, the Department of Justice (DOJ) and the Department of Health and Human Services will soon target three additional cities, establishing strike force offices in Baton Rouge, Tampa and Brooklyn. Enforcement teams that include these two agencies plus the FBI and DEA are housed in strike force centers.
The Medicare fraud strike forces are multiagency teams of federal, state and local investigators designed to detect and prosecute fraud. In addition to DOJ and HHS, these strike forces involve the Federal Bureau of Investigation (FBI) and the Drug Enforcement Agency (DEA). The strike forces use real time data analysis to stop fraud as it occurs.
According to Attorney General Eric Holder, Medicare and Medicaid fraud cost the government billions of dollars each year. In an effort to combat these problems, DOJ and HHS have established a new taskforce, the Health Care Fraud Prevention and Enforcement Action Team (HEAT).
An FBI agent caries a computer seized from Courtesy Medical Group, Tuesday, Dec. 15, 2009 in Miami. Federal agents arrested several suspects and expected to roundup about 30 in three states Tuesday on charges related to Medicare fraud totaling $61 million as the government cracks down on waste under health care overhaul plans. (AP Photo/Wilfredo Lee)
On December 16, the Department of Health and Human Services announced the new strike force offices in Baton Rouge, Tampa and Brooklyn. The strike forces have focused on states that spend the most money on Medicare per person. According to HHS, Louisiana spent $8,659 per enrollee in 2004, the highest in the country. Previously, the Houston strike force office handled all of Louisiana.
Types of Medicare Fraud
Medicare fraud can involve a variety of activities. Most commonly, this fraud involves the billing and coding for services, for example:
-Billing for services not provided
-Billing for equipment not provided
-Billing for services that are not medically necessary
-Improperly coding for services
-Double billing
However, fraud may also involve some type of improper financial relationship between a physician and an entity providing health care. For example, an anti-kickback law prohibits any type of payment in return for referring a patient. A physician self-referral law prohibits a doctor from having a financial relationship with an entity to which he or she refers a Medicare patient.
Civil and Criminal Liability
Last year the DOJ filed 502 criminal health care fraud cases with charges against 707 defendants, ultimately resulting in 588 convictions. The average prison sentence was more than three years (37.4 months).
Many federal statutes deal with health care fraud. Some specifically apply to health care fraud, like the anti-kickback law and the law against self-referral. Others are general laws that can be applied to health care fraud, such as the False Claims Act, Racketeer Influenced and Corrupt Organizations Act (RICO) and money laundering laws.
New State-Based Medicaid Strike Force Teams
In addition to the Medicare strike force teams, DOJ and HHS are encouraging the states to establish their own Medicaid strike forces using some of the same tools used by the Medicare strike forces, such as real time data analysis. These strike forces are working together to help eliminate fraud and investigating fraudulent operators who are cheating the system and costing taxpayers money.
Recommendations
These investigations are very serious and anyone convicted of Medicare of Medicaid fraud charges faces severe consequences. Owners of home care agencies and hospices who discover they are under investigation should treat the situation with utmost seriousness and speak to a criminal defense attorney immediately.
December 22nd, 2009 at 10:05 am
It’s good to see efforts being taken to stop Medicare fraud. Another good resource about fraud and things to do and watch out for to prevent Medicare fraud can be found at http://...
December 22nd, 2009 at 6:39 pm
Allison,
Thank you for your kind comment and support. If you would care to use our newsletter to promote your service helping to drive Medicare beneficiaries to Medicare Advantage plans, please feel free to contact our advertising consultant at kristin@homehealthnews.org.
Sincerely,
The Editor
December 28th, 2009 at 12:14 pm
We have worked very hard in many ways to draw such attention. This enforcement is long overdue. unfortunately it will come with significant amounts of collateral damage.
2010 is going to be an amazing eye opener of federal activity pointed directly at home-care providers.
Protecting yourself is easy but you must make a real effort at it as it will not just happen…….
December 28th, 2009 at 2:55 pm
Michael is correct. Fraud accusations can result from intentional illegal activity or from mere sloppiness. Fiscal intermediaries and RACs will be looking for documentation errors or omissions that will allow them to take back payments you have already received and probably spent. And now the FBI and DEA will be helping HHS determine whether you should also pay huge fines and possibly do some jail time. If your agency is in business for the purpose of defrauding Medicare, this would be a good time to close up shop and find a different scam to run. If you are organized for the purpose of providing excellent patient care, this would be a great time to enhance your clinical training program, especially in the area of assessment and visit note documentation. Our sister newsletters, Home Care Technology Report and The Informed Home Care Clinician will soon be running a list of state association and vendor training offerings.
Tim
March 3rd, 2010 at 6:40 pm
Fraud accusations have been reported from one agency against another to hinder competition. What a world of sharks we are living in!