Articles Posted in Anti-Fraud Enforcement

BigStock_KickBackTypically, when I meet with clients for the first time, it never ceases to amaze me that they have little or no idea what constitutes Medicare fraud is and didn’t know they couldn’t be doing the things they were doing.  So, I decided to write this post to give a primer to explain: what is Medicare Fraud?

For those who are working in the medical field, whether they are doctors, corporate owners of medical practices, pharmacists, pharmacy owners, lab owners, durable medical equipment business owners, just to name a few, it can’t be overemphasized that it is essential to be familiar with the basics of Medicare fraud.

With this in mind, I want to make sure you are informed about how someone can get themselves in trouble. In general, Medicare fraud refers to submitting a false claim in a Medicare beneficiary’s name to a governmental sponsored health care program for reimbursement.

Photobucket BOSTON, MASSACHUSETTS (AUGUST 29, 2011) – Massachusetts State Attorney General Martha Coakley’s office released information that it had recovered $69 million in Medicaid fraud during the fiscal year 2011. The previous record was $14 million in 2009.
Since she took office in 2007, AG Coakley’s office has added $200 million in Medicaid fraud back to the state fund’s coffers. The $69 million figure alone represents more than the total previously collected in the ten years prior to Coakley’s tenure. For every dollar the AG’s Medicaid Fraud Division has allocated to its budget, $18 is recovered to the taxpayer.

Photobucket NEWARK, NEW JERSEY (AUGUST 2, 2011) – The FBI wants the public’s help in preventing health care fraud and they’re putting up advertisements in malls and on highways to bring attention to their campaign. Digital ads went up in malls in Paramus, Wayne, Hackensack and Atlantic City, as well as on the Jersey Turnpike near the Lincoln Tunnel and several major highway systems.

The Newark office of the FBI is credited with the idea for the program. For the next two months that the ads are up, the Bureau hopes to see an increase in the number of tips reporting health care fraud. If the New Jersey campaign is successful, the Bureau will turn it into a national program with the help of Clear Channel, who also assists on the “Most Wanted” digital billboards.

Health care fraud costs the American taxpayer approximately $60 billion a year, and in New Jersey the loss was $8 million in 2010. As the number of reported health care fraud cases has fallen off in recent years, the FBI hopes to educate the public on how much they’re losing by not reporting fraud. Agent Sean Keyes says “all of the best criminal investigations are human-source driven.”

Photobucket TAMPA, FLORIDA (AUGUST 1, 2011) – The Office of the Inspector General in the Department of Health and Human Services is now calling Tampa, “ground zero for pain clinics and prescription drug diversion.” It seems Tampa has taken South Florida’s place in the number of pill mill clinics supplying the illegal painkillers trade. Chris Rule of the Hillsborough County Sheriff’s office said it likens back to the crack cocaine problem in the 1990s.

The death toll is rising. Out of 277 drug-related deaths in 2009, 199 of those could be attributed to an oxycodone overdose or other cocktailed drugs. And Rule further states that opiate-based painkillers are the easiest drugs to buy on the street these days. In order for the patients or dealers to get the drugs from the clinic, they need only submit to a blood pressure screening or an MRI.

Of the 70 pain clinics located in the county, 35 are in Tampa. Rule says he doesn’t feel every clinic is illegal trading in prescription painkillers. Some operate within the confines of the law and “some are shady,” he says.

Photobucket MIAMI, FLORIDA (JULY 26, 2011) – The Government Accountability Office recently issued a report stating the federal government’s analysis systems for Medicare and Medicaid are “inadequate and underused.” The report further reveals that the systems don’t even analyze Medicaid data, and of the 639 analysts targeted for training with the system, only 41 have received it. The technology slated to save $21 million in Medicare and Medicaid lacks the formal planning for implementation, even though $150 million has been invested in the technology.
When the new system went live in 2009, it was intended for use by the Center for Medicare and Medicaid Services (CMS), contractors, law enforcement and state agencies, with access to the information shared across all states. Because funding for the software was delayed, the rollout date has been pushed to November 2011.
In the meantime, CMS has another fraud prevention technology program in the works, similar to the system that screens for credit card fraud. That contract came with a $77 million price tag. With approximately 4.5 million claims processed on a daily basis, rollout of these programs can’t come fast enough for the taxpayer’s wallet.

PhotobucketWASHINGTON D.C. (JULY 13, 2011) – In an effort to prevent billions lost each year in fraudulent Medicare claims, a nationwide computer system for tracking claims was launched in South Florida. The system is designed to examine the millions of daily claims for reimbursement using “predictive modeling,” which can identify suspected hot beds of suspicious activity throughout the country.
To avoid detection, business owners who intend to defraud the Medicare system will often move their business to other areas of the country and begin working the same scam in the new locale. In June, law enforcement charged 21 alleged fraudsters in a $23 million scam; 15 of which were from Michigan, the other six from Florida. Strike force investigators have located Medicare criminal fraud networks extending from Miami to Detroit and Houston to Los Angeles. Since March 2007, strike force investigators have identified that $1.85 billion in fraudulent claims originated in South Florida, which represented the largest portion of the total $2.3 billion nationwide. Officials estimate that Medicare fraud could total as much as $60 billion per year.
In the past, Medicare reimbursements paid first and then examined the claims for discrepancies, which investigators dubbed “pay and chase.” The new system will screen and analyze claims first before payouts are made. If any healthcare providers are found to be submitting suspicious claims, they will first be excluded from participating in the Medicare system and then turned over to law enforcement.

Photobucket WASHINGTON D.C. – Health care fraud task forces are turning their attention to the executive level of health care enterprises. In an effort to crackdown on those who would perpetrate health care fraud, investigators have begun aiming their efforts at the owners and operators of drug companies, medical device manufacturers, nursing home chains and any health care business involved with Medicare and Medicaid. Senior executives could find themselves facing criminal charges even if they had no knowledge of their company’s activities, but were in a position to stop it.

Prosecutors have become fed up with repeated violations, which cost taxpayers more than $60 billion per year and have decided to use enforcement tools that have long been in place, but simply not used. A simple writing of a check to repay the federal funds and a promise not to repeat the offense have been used too often, so now corporate executives must pay closer attention to how their company is billing Medicare and Medicaid lest they find themselves in hot water with the feds.

The crackdown may result in a company’s ban from participating in Medicare and Medicaid reimbursements, but the power to ban lies solely with the inspector general, not a judge. The FDA has also begun using the “Park Doctrine” which allows prosecutors to bring criminal charges against executives. Any corporate officer in the chain of command could charged with a criminal misdemeanor if found to have the ability within their power to prevent the fraud.

Photobucket WASHINGTON D.C. – The Office of the Inspector General of the Department of Health & Human Services has been working hard. In its semi-annual report for October 2010 through March 2011, the OIG’s office reported that it expected to recover approximately $222 million from audits and another $3.2 billion from criminal and civil actions. As a result of investigations during that time period the OIG also doled out 883 new exclusions to persons and entities, barring them from participating in Federal health care programs.

The OIG’s report continued by revealing more than 100 perpetrators of health care fraud had been arrested, and in February 2011, Medicare Strike Force teams with more than 300 agents fanned out across the country and arrested more than 100 suspects in nine cities. Owners and executives of health care service companies, doctors and nurses, among others found themselves accused of fraudulent billing practices, money laundering, receipt of kickbacks and identity theft.

The OIG’s success resulted from a collaborative effort with the Department of Justice, the Centers for Medicare & Medicaid Services, State Medicaid Fraud Control Units, other OIGs offices, State agencies and local law enforcement.

Photobucket MIAMI-DADE, FLORIDA (May 19, 2011) – A fraudulent billing scam masterminded by Gregory Campbell, the 28-year-old son of State Rep. Daphne Campbell, has brought first-degree felony charges of grand theft, organized fraud and Medicaid fraud down on Mr. Campbell’s head. He stands accused of billing the joint state and federally funded Medicaid program for $299,000 for services he never provided.

It appears Campbell billed for the same patients at two separate adult care facilities. Investigators also found Campbell billed for patients that did not live at either facility, and he offered kickbacks to the owner of one of the care sites.

Campbell was being held in the Miami-Dade county jail following his arrest on May 12. When contact by the press regarding her son’s arrest, Rep. Campbell had no comment.

Photobucket PALM BEACH COUNTY, FLORIDA (May 26, 2011) – State Attorney Michael McAuliffe and Sheriff Ric Bradshaw will co-host Palm Beach County’s Prescription Drug Abuse and Pain Clinic Summit. The event takes place today, May 26, from 9 a.m. to 12:30 at the Clayton Hutcheson Agricultural Center.

The summit focuses on prevention of the consequences surrounding addiction and prescription drug dealing before they occur.

This is the summit’s second year and since that time the number of pain clinics dealing in the illegal prescription drug trade has dropped significantly; due in part to law enforcement’s wide-sweeping raids.

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