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ericHolder.jpgMIAMI (July 16) – U.S. Agents have arrested 94 doctors, health care owners, and executives in a nation-wide crack down on fraudulent medicare billing, U.S. Attorney General and Health and Human Services Secretary Kathleen Sebilius announced today in Miami, where 24 of those people were arrested. After the announcement, Secretary Sebilius visited offices near the Miami airport, where nine people have been arrested since 2004, to see examples of empty storefronts of purported health care businesses.
To read the U.S. Attorney’s press release, click: here.
To watch a video of the announcement of the operation produced by the Miami Herald’s Chuck Fadely, click: here.sebeliusThumbnail.jpg

ericHolder.jpgMIAMI (July 16, 2010) – U.S. Health and Human Services Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder today kicked-off the first in a series of Regional Health Care Fraud Prevention Summits in Miami, Florida. The summit brought together a wide-array of federal, state and local partners, beneficiaries, providers, and other interested parties to discuss innovative ways to eliminate fraud within the U.S. health care system.

“The days of scamming dollars from our health care system are over,” said Secretary Sebelius. “Thanks to new tools contained in the Affordable Care Act, we are more prepared than ever to safeguard taxpayer dollars and ensure that the health care coverage of our seniors, families and children is secure. I’m proud of the tremendous success we’ve had so far, and look forward to continuing this important dialogue at fraud prevention summits across the country.”sebeliusThumbnail.jpg

“Despite all that’s been accomplished over the last year, we cannot yet be satisfied or become complacent. And we cannot ignore the fact that health care fraud remains a significant problem, said Attorney General Holder. “Each of you can be part of this and other public education efforts. Each of you can help to ensure that our health reform achievements are not exploited.”

ericHolder.jpgWASHINGTON (June 8, 2010) – Attorney General Eric Holder and Secretary of Health and Human Services (HHS) Kathleen Sebelius have sent a letter to state attorneys general urging them to work with HHS and federal, state and local law enforcement officials to mount a substantial outreach campaign, beginning this summer, to educate seniors and other Medicare beneficiaries about how to prevent scams and fraud. The outreach campaign is another step in the ongoing work of HEAT – the Health Care Fraud Prevention Enforcement Action Team, a cabinet-level initiative launch by the Justice Department and HHS in May 2009. For more on HEAT, click: here.
“We are heading into the week when our first tax-free $250 donut hole rebate checks will be mailed out to Medicare beneficiaries who have fallen into the coverage gap. Accordingly, we are especially concerned about fraud and increased sebeliusThumbnail.jpgactivity by criminals seeking to defraud seniors – and we are seeking your help to stop it,” said Attorney General Holder and Secretary Sebelius in the letter. “Building on our record of aggressive action, we will use the new tools and resources provided by the Affordable Care Act to further crack down on fraud.”
In the letter, the Attorney General and Secretary outline education and outreach efforts where state attorneys general could make a big difference. These include efforts to cut the improper payment rate, which tracks fraud, waste and abuse in the Medicare Fee for Service program, in half by 2012; a series of regional fraud prevention summits around the country over the next few months; regular health care fraud task force meetings to facilitate the exchange of information with partners in the public and private sector, and to help coordinate anti-fraud effort; HHS’s plans to double the size of the Senior Medicare Patrol and to put more boots on the ground in the fight against Medicare fraud; and a new educational media campaign this summer to educate Medicare beneficiaries about how to protect themselves against fraud.

confidential-file.jpgFlorida and a number of states attempting to outlaw so called ambulance chasing in personal injury cases have employed several methods to limit access to records of patients. First, statutes prohibit access to police accident reports for 60-days. Second, statutes as well as professional rules regulating the professional conduct of lawyers and health care license holders prohibit the direct solicitation of patients for services.

Nevertheless, there have been some novel ways developed to get around those laws, including every once in a while someone starting a “newspaper” to use a media exception to the rule regarding access to accident reports. With restrictions on direct access to accident information, a black market for patient information has developed as well as intricate referral networks, including everyone involved in accidents, from tow truck drivers and auto body employees, to ambulance service employees, to hospital employees.

All these involve payments of one type or another, generally in cash, for access to that information and people who employ themselves gathering that information. In a recent case, a Miami man was indicted for a second time for bribing employees, first of an ambulance company, and then hospital employees to get patient information for personal injury attorneys.

silence.jpgWhatever you do, don’t harass the Medicare fraud investigators. A kind of simple rule, if you are committing a crime (no one I represent does that), don’t go out of your way to send harassing emails and phone calls to investigators, including death threats; it tends to incentivise them a bit to arrest you.
To read what happened to one defendant who couldn’t get out of his own way, click here.

CMS uses contractors to process claims, but also to use sophisticated software to detect fraud patterns and make referrals for claims denials, audits and criminal investigations. At one time the system was somewhat fragmented, given that there are different contractors who process part A, B and D claims in given regions and a series of contractors were looking at data based upon particular types of claims or criteria. In addition, the flow of data prevented the contractors from analyzing and detecting fraud patterns until long after claims had been paid. Lately, CMS has moved to contractors who electronically review all claims for 7 regions searching for claims patterns that reflect fraud. The program, called ZPIC (Zone Program Integrity Contractors) has led, at least at the inception, to many providers receiving audit inquiries, chart reviews, and application renewals; and according to the program, the denial of $1.5 billion in claims in Florida alone since May.
Click here to read more.

We have done posts on the various monikers given to task forces, including the most recent in healthcare fraud, HEAT (Healthcare Fraud Prevention and Enforcement Team) and the agencies in involved in those investigations; the FBI (Federal Bureau of Investigation), OIG (Office of Inspector General), MFCU (Medicaid Fraud Control Unit); but the British, when they go to investigate large frauds have a more direct name, “Serious Fraud Office” which in England and Wales is a separate entity from the other governmental agencies and has specific criteria as to the amounts number of potential victims, and the general importance of the prosecution.
In the healthcare field, their most recent investigations have involved frauds on the British healthcare systems by drug manufacturers. The analogous agency in the United States would likely be the Department Of Justice or Main Justice and one of its individual units, but the names aren’t as cool. On the one hand, getting a visit from the Federal Bureau of Investigation is frightening, but it might be more so if you get an investigation from the Serious Fraud Office.
Click here to read more.

MIAMI, FL (October 12, 2009) Today the editorial board of the Miami Herald weighed in on the national health care reform debate by pointing out that the current health care system – Medicaid and Medicare – has insufficient front-end mechanisms in place to detect fraud, waste and abuse and by calling for stiffer sentences saying, “unless penalties for fraudsters who steal millions of dollars are toughened so that the prison sentence is more than a legal slap, they’ll keep scamming.”

The Herald offered up some eye opening statistics. Since 2005, federal prosecutors in South Florida have charged more than 900 Medicare offenders in cases totaling more than $2 billion in fraudulent claims. Across the U.S., taxpayers are hit with $60 billion in healthcare fraud each year.

In an effort to shape national healthcare policy, the editorial urged called on the President to press for more investigators to catch abuses when claims are first filed — not down the road when government investigators and auditors eventually detect that millions have been erroneously paid out to crooks, some of whom have flown the coop.

cat%20burglar.jpgOf general interest and with particular application in health care, the federal government has, over the course of several decades, criminalized an entire range of behavior that most people did not know or perceive to be criminal. This is not lost on the people who practice in the medical field; one client recently surmised “If it is a good idea in healthcare, it is probably a misdemeanor, if it is a great idea, it’s a a felony.”

One other client, after being acquitted of federal criminal charges predicated upon the application of a vague regulation, asked “What did I do wrong?” The only answer I could come up with was “You made money in health care.”

The intricate and ever expanding number of regulations, national and local coverage determinations, and transmittals from Medicare and Medicaid often carry with them potential criminal penalties for fraudulent claims. Fox News has an interesting article about hearings being conducted by Congress on the issue of the over criminalization of federal law.

flames.jpgA new moniker in the long list of federal task forces. Federal Agencies generally get the three letter moinker; FBI, IRS, CIA, OIG, DOD, etc. Task forces get more letters and try to do acronyms; HIDTA (DEA), FinCEN, OFAC (Treasury), OCDETF (DOJ).
Now we finally have a task force with a cool name: HEAT (Health Care Fraud Prevention and Enforcement Action Team). And they have been busy between Miami, Detroit and Huston. In one week, six indictments and allegations of $282 million in fraud from DME, to Pain Management, to therapy.
For more, click here.

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