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National Medicare fraud crackdown uncovers $233 million in false billings

Pills Stethascope on Money 435x289 National Medicare fraud crackdown uncovers $233 million in false billingsA federal crackdown on Medicare fraud in eight cities nationwide has led to charges against 89 individuals, including doctors, nurses, and other licensed medical professionals, for their alleged participation in fraud schemes that resulted in about $233 million in false Medicare billings, the U.S. Justice Department has announced.

The crackdown was the sixth such operation orchestrated by the Medicare Fraud Strike Force since it was first formed in 2007. The task force now operates under the federal Health Care Fraud Prevention & Enforcement Action Team (HEAT), a joint initiative created by the Justice Department and the Department of Health and Human Services in 2009. The Task Force has expanded to included Baton Rouge, Brooklyn, Chicago, Dallas, Detroit, Houston, Los Angeles, Miami–Dade, and Tampa Bay.

With federal taxpayer-funded health care budgets under strain and facing devastating cuts, cracking down on Medicare and Medicaid fraud has become a national priority. To date, the Medicare Fraud Strike Force crackdowns have resulted in charges against nearly 600 individuals over false claims amounting to about $2 billion.

The qui tam or “whistleblower” provisions of the False Claims Act (FCA) are another important tool in the federal government’s fight to recover taxpayer funds. The law allows private individuals to act as the “eyes and ears” of the federal government and file a lawsuit on its behalf when they possess sufficient evidence of fraud, waste, mismanagement, and other wrongdoing. In exchange, whistleblowers share a percentage of the recovery, usually about 25 percent, but occasionally as high as 30 percent. Whistleblower laws are particularly effective in fighting financial fraud committed by large pharmaceutical companies, hospitals and other health care corporations.

The defendants charged in the Task Force’s latest sting operations are accused of various health care fraud-related crimes, including conspiracy to commit health care fraud, violations of the anti-kickback statutes, and money laundering. The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, primarily in the home health care industry, but also in mental health services, psychotherapy, physical and occupational therapy, durable medical equipment (DME), and ambulance services.

According to court documents, the defendants allegedly participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and often never provided. In many cases, court documents allege that patient recruiters, Medicare beneficiaries, and other co-conspirators were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent billing to Medicare for services that were medically unnecessary or never performed.

“Today’s announcement marks the latest step forward in our comprehensive efforts to combat fraud and abuse in our health-care systems,” said U.S. Attorney General Eric Holder. “These significant actions build on the remarkable progress that the HEAT has enabled us to make – alongside key federal, state, and local partners – in identifying and shutting down fraud schemes. They are helping to deter would-be criminals from engaging in fraudulent activities in the first place. And they underscore our ongoing commitment to protecting the American people from all forms of health-care fraud, safeguarding taxpayer resources and ensuring the integrity of essential health-care programs.”

“The Affordable Care Act has given us additional tools to preserve Medicare and protect the tens of millions of Americans who rely on it each day,” said Secretary Sebelius. “By expanding our authority to suspend Medicare payments and reimbursements when fraud is suspected, the law allows us to better preserve the system and save taxpayer dollars. Today we’re sending a strong, clear message to anyone seeking to defraud Medicare: You will get caught and you will pay the price. We will protect a sacred trust and an earned guarantee.”


U.S. Department of Health and Human Services