A former financial planner at the Tampa company WellCare pleaded guilty to conspiring to defraud the Medicaid program. He is now testifying in the criminal trials against four executives of WellCare in connection with the same Medicaid fraud activities. The company is accused of sending false information regarding how much state money WellCare spent of providing mental health services for its patients.
As another indicator of the government's aggressive focus on Medicare and Medicaid fraud, federal investigators seized 92 people across the country. The defendants, including 34 people from Miami, will face federal fraud charges. Overall, the government says that these cases represent $432 million in fraud.
North Carolina is one of many jurisdictions testing new methods to avoid overpaying for Medicare and Medicaid expenses. IBM has developed software that uses predictive analytics to unearth potentially fraudulent Medicaid payments. The fraud detection software analyzes millions of claims for Medicaid eligible patients and looks for billing patterns that have been identified as potentially fraudulent. The goal of the systems is generally to avoid approving improper payments rather than waiting to pursue civil remedies from hospitals, doctors and other health care providers for Medicare or Medicaid fraud after the money has changed hands.
The Justice Department began targeting Medicare fraud in 2007 as a national crisis. Since then they have been aggressive in their pursuit and prosecution of anyone they suspect may have been involved in Medicare fraud.
A Florida-based insurer recently agreed to pay nearly $140 million to the federal government and to nine states to resolve claims that it overbilled Medicare and Medicaid.
The Justice Department and the Department of Health and Human Services concluded that the Good Samaritan Hospital used leading questions in determining that some patients were suffering from malnutrition. Federal investigators accused the hospital of committing Medicaid and Medicare fraud based on the enhanced reimbursement rate the hospital could claim for patients due to the malnutrition finding. The hospital agreed to pay nearly $800,000 in penalties to settle the matter while stating, "We have provided the highest level of quality care to our patients in accordance with all laws and regulations."
State officials released the results of the 2011 fiscal year recently. In total, the state is claiming it recovered $142 million in Medicaid fraud actions. That number comes from a report filed by the Florida Attorney General's Office and the Florida Agency for Health Care Administration. The time and resources used to investigate and prosecute Medicaid fraud cases has grown in recent years. The increased emphasis comes as the government looks to justify the increasing budget dedicated to Medicare and Medicaid.
Prosecuting health care professionals and businesses has become big business in Washington D.C. In 2010, the government obtained more than $1.85 billion in Medicaid fraud prosecutions. That is nearly three times the amount they gained just six years prior. The money gained is a reflection of the increase in the money the government now spends investigating and prosecuting health care fraud.
A New York hospital reached an agreement with federal prosecutors to pay roughly $13.4 million to avoid a trial. The hospital was facing charges that it made more than 2,000 fraudulent Medicaid claims in connection with its detoxification and drug treatment programs. The false claims generated over $9 million in Medicaid payments from the federal government. Health care professionals and medical facilities all over the country are facing increased scrutiny as government officials address problems with the Medicare and Medicaid programs.