Federal Government Cracking Down On Medicare Fraud

Article provided by Frank Rubino

Medicare fraud costs tax payers billions of dollars every year. As a result, the Justice Department and the Department of Health and Human Services (HHS) are partnering in a joint agency effort to combat Medicare fraud. In May, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius announced the formation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT). Agents from both the FBI and HHS will work together to stop providers, doctors and other individuals from abusing the Medicare system.

Along with the formation of HEAT, Secretary Sebelius and Attorney General Holder also announced an expansion of the Medicare Strike Force teams currently in operation in Los Angeles and South Florida. These teams will now be targeting instances of Medicare fraud in the Detroit and Houston areas as well.

Common Types Of Scams

Over 45 million Americans depend on the Medicare system to receive the medical treatment they need. The costs of fraud affect the entire Medicare system and drive up the costs for everyone, not just those who are covered by Medicare.

Most errors in Medicare payments occur as the result of clerical mistakes and are not the result of providers or physicians attempting to game the system. Unfortunately, according to HHS, the few providers and doctors that engage in Medicare fraud costs taxpayers tens of billions of dollars every year.

The most common type of scam involves Medicare providers intentionally billing Medicare or another insurance company for services that were never performed or that are different from the services actually provided. Other types of Medicare fraud include:

• Charging co-payments for preventive services covered by Medicare.
• Providers encouraging unnecessary services, claiming they are required by Medicare.
• Telling patients that tests or services are free.
• Paying a kickback to use someone’s Medicare number to submit a claim.
• Using someone else’s Medicare card to get care or services.

These scams can involve only a few people or they can be sophisticated operations with many participants. These expansive schemes can filter millions of dollars to doctors and providers through false claims and other fraudulent billing practices.

The Use And Effectiveness Of Strike Force Teams

HHS and the Justice Department have previously used Strike Force teams in South Florida and Los Angeles to target patterns of suspicious billing. Attorney General Holder had noted that the success of these operations in South Florida likely drove the participants of the scams to other areas, including Houston.

Since the inception of the program in March 2007, Strike Force teams have arrested over 250 people in connection with fraud operations that have totaled more than $600 million dollars in Medicare losses.

Each Strike Force team is lead by a federal prosecutor, and includes four to six members, with at least one member from the FBI and the HHS Office of Inspector General. These teams are “data driven,” using mathematical evaluations to determine billing irregularities and patterns.

The HEAT and Strike Force teams are technology based, using state-of-the-art technology to identify and prosecute Medicare fraud. Previously, it could take months to analyze the data that would lead to an arrest and prosecution. Now, this same information can be analyzed in only a few days. The speed and efficiency of the analysis, as well as improved data sharing between HHS and law enforcement, will significantly expand both agencies ability to crack down on perpetrators of Medicare fraud.

This initiative is only part of the government’s effort to crack down on Medicare fraud. Officials also encourage individual citizens to report suspected cases of fraud and abuse of Medicare through the Medicare.gov Web site.

With the new emphasis on Medicare fraud and the resources dedicated to preventing it, the number of arrests and subsequent prosecutions will likely increase over the next few years. For those doctors or providers who are accused of Medicare fraud, it is more important than ever that they consult with an experienced criminal defense attorney