Health Care Fraud Prosecutions Set To Increase 85% This Year

Fraud and abuse prosecutions are predicted to rise 85% over those from last year as the Obama administration ramps up its commitment to crack down on waste and fraud in the government, according to a recent USA Today article.

 The statistics as released by the non-partisan Transactional Records Access Clearinghouse (TRAC), show 903 prosecutions so far this year. This is a 24% increase over fraud cases in 2010, when there were 731 prosecutions. Prosecutions have gone up 71% from five years ago, according to TRAC.

“That’s just a stunning number when you see it in the first eight months… We’re just going to build on this model, and we’re going to hold those responsible who are stealing from the government,” Assistant Attorney General Lanny Breuer commented.

 The increase is partially due to the largest conviction to date, which brought in 111 people for fraud in February. Doctors, nurses and other defendants were charged with Medicare crime schemes that exceeded $225 million in false billings. The charges involved defendants in nine cities.  

“The defendants were charged various crimes, including conspiracy to defraud the Medicare program, false claims, kickbacks and money laundering,” administration officials said.

Home health, physical and occupational therapy and durable medical equipment, among other types of health care were involved.

 And all of this can be traced back to parts of the Patient Protection and Affordable Care Act (P.L. 111-148), which, according to a CMS release, “provides critical new tools to improve and enhance the Administration’s ongoing efforts to prevent and detect fraud, and crack down on individuals who attempt to defraud Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) as well as private insurance.”

 Task force convictions have also increased, according to the Department Of Justice. Just last year, there were 23 trial convictions for Medicare fraud, but so far, in the first eight months of 2011, the task force has seen 24. Two health care fraud teams that were added this year – Chicago and Dallas as part of the Medicare Fraud Strike Force.

 In a press release earlier this summer, CMS announced an administration-wide initiative to crack down on waste, fraud and abuse.

  “President Obama is committed to hunting down and eliminating waste, fraud and abuse throughout the federal government,” said HHS Secretary Kathleen Sebelius. “Our work to fight Medicare fraud is an important part of the Obama Administration’s effort to root out wasteful spending and change the way government does business.”

 In the past, the government relied on whistleblowers to come forward. Now, CMS is using “innovative predictive modeling technology” to fight Medicare fraud. This technology is similar to that used by credit card companies. Predictive modeling helps to identify potentially fraudulent Medicare claims on a nationwide basis, and help stop fraudulent claims before they are paid, according to CMS.

This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made. 

This new technology is “bad news for criminals looking to take advantage of our seniors and defraud Medicare,” said CMS Administrator Donald Berwick, M.D. and “will help us better identify and prevent fraud and abuse before it happens and helps to ensure the solvency of the Medicare Trust Fund.”

These new technologies represent only one way the government is cracking down on fraud. With the $350 million allocated to preventing fraud that was provided by the Affordable Care Act, things seem to be headed in the right direction.