Government Activity on Medicare Fraud and Abuse Investigations Increasing

 Earlier in the month the Department of Justice and the HHS Insepctor General announced a a nationwide takedown by the Medicare Fraud Strike Force operations in eight cities that resulted in charges against 91 defendants, including doctors, nurses, and other medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $295 million in false billing.

As part of the coordinated action, 70 individuals were charged by Strike Force prosecutors  in six cities alleging a variety of Medicare fraud schemes involving approximately $263.6 million in false billings.  As part of the takedown operations, 18 individuals were charged in Detroit and one defendant was charged in Miami in cases  for their alleged roles in Medicare fraud schemes involving approximately $29.4 million in fraudulent claims.  This coordinated takedown involved the highest amount of false Medicare billings in a single takedown in Strike Force history.

In Miami, 45 defendants, including one doctor and one nurse, were charged for their participation in various fraud schemes involving a total of $159 million in false billings for home health care, mental health services, occupational and physical therapy, DME and HIV infusion.  Six defendants, including two doctors, were charged in Los Angeles for their roles in schemes to defraud Medicare of more than $10.7 million.  In Brooklyn, three defendants, including two doctors, were charged for a fraud scheme involving more than $3.4 million in false claims for medically unnecessary physical therapy.  In Detroit, 18 defendants, including three doctors, were charged for schemes to defraud Medicare of more than $28 million.  According to an indictment, 14 of the defendants participated in a home health care scheme that submitted more than $14 million in false claims to Medicare.  Finally, four defendants including one doctor were charged in Chicago for their alleged roles in schemes to defraud Medicare of more than $4.4 million.

HHS Secretary Sebelius stated the 91 arrests “illustrate close cooperation between the Medicare program that identified these fraudsters and the law enforcement officials who acted swiftly to cut them off.  And our efforts to stop criminals don’t end here because the Affordable Care Act gives us new tools to prevent Medicare fraud before it is committed – better protecting seniors and the integrity of the Medicare program for generations to come.”

Later in the month, a Maryland-based health care company accused of defrauding Medicaid and other federal programs agreed to  pay $150 million in a settlement.   The company was accused of  health care fraud for submitting claims for services that were never provided and operating offices that weren’t properly licensed.

Since the beginning of Spetmeber two Ohio based  healthcare organizations each  agreed to pay  pay $3.8 million to settle allegations of health care fraud.

The Government Accountability Office reported that the Centers for Medicare & Medicaid Services has expanded its anti-fraud efforts after receiving increased funding from Congress and reallocating money saved from Medicare contractor consolidations since 2006.  In 2010 Medicare spent  $1 billion fighting fraud and ensuring the accuracy of payments for health care services in 2010.  In addition, the Budget Control Act of 2011  provided CMS with an additional $350 million for fraud and abuse control efforts.

Sen. John McCain (R-Ariz.) stated  that CMS is headed in the right direction, but he also noted that an unacceptable amount of money is still lost to fraud on an annual basis. The Medicare program spends about $500 billion a year, a figure that included an estimated $48 billion in improper payments in 2010.