Medicare Compliance & Reimbursement

False claims, kickbacks, drug offenses — this massive ‘takedown’ has it all.

If you were hoping for some relief from the daily grind of federal healthcare scrutiny, think again. Last month’s combined efforts of the Department of Justice (DOJ) and the HHS Office of Inspector General (OIG) suggest the government’s health law enforcers are just getting started.

Background: The interagency group, the Medicare Fraud Strike Force, announced a banner day in its fight against fraud and abuse. Its “National Health Care Fraud Takedown” — the largest criminal health law enforcement actions in the combined groups’ histories — involved 412 charged defendants across 41 federal districts, including 115 doctors, nurses, and other licensed medical professionals, for their alleged participation in healthcare fraud schemes involving about $1.3 billion in false billings, the DOJ and OIG said in a release. HHS has initiated suspension actions against 295 providers, including doctors, nurses, and pharmacists, and 30 state Medicaid Fraud Control Units participated in that day’s arrests.

Read the DOJ release at: www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-charges-against-over-412-individuals-responsible.

“While today is a historic day, the Department’s work is not finished. In fact, it is just beginning,” said Jefferson Sessions, U.S. Attorney General in the DOJ release. “We will continue to find, arrest, prosecute, convict, and incarcerate fraudsters and drug dealers wherever they are.”

Take A Look At A Few Of The Highlights

As the nation’s opioid crisis continues to be high on the HHS-OIG’s checklist, it’s not surprising that a majority of the cases focused on prescription drug schemes. False claims and kickbacks related to a variety of issues figured heavily in the takedown as well. Some of the biggest offenders and charges delivered included the following examples:

In Florida: The various Strike Force conglomerates in Florida netted 77 defenders with a variety of crimes related to “home health care, mental health services and pharmacy fraud” that added up to more than $141 million in false billing, the release noted. Fraudsters lured addicted patients into false treatment schemes as well, offering them kickbacks that included more drugs for assisting in the falsification of testing and treatment.

In addition to having the largest number of defendants, Florida also delivered the highest charge to a single individual. The perpetrator, who allegedly owned and operated an “addiction treatment center and home for recovering addicts,” submitted “over $58 million in fraudulent medical insurance claims for purported drug treatment services,” the release said.

In Michigan: Drug running, kickbacks, and even money laundering were interwoven into the false claims charges against 33 defendants in Michigan that equaled more than $218 million for services that were either medically unnecessary or never performed, OIG and DOJ suggested.

In California: Two out of the 17 defendants accounted for $41.5 million of the $147 million total fraud cache for allegedly cheating Medicare and another private payer by submitting false claims and prescriptions for services and drugs unfulfilled, indicated the Task Force information.

In Illinois: Fifteen individuals were charged in cases related to six different schemes concerning home care and physical therapy fraud, kickbacks, and mail and wire fraud. These schemes involved more than $12.7 million in fraudulent billing. “One case allegedly involved $7 million in fraudulent billing to Medicare for home health services that were not necessary nor rendered,” the OIG and DOJ said.

What Lessons Can We Learn From The Indictments?

Lesson 1: If you peddle prescription drugs, you’ll feel the feds’ hammer of justice. Drug diversion was the predominant offense across the various cases. With no end in sight to the opioid addiction and illegal distribution epidemic gripping Medicare, expect tighter controls and higher penalties.

“There is a great responsibility that goes along with handling controlled prescription drugs, and DEA and its partners remain absolutely committed to fighting the opioid epidemic using all the tools at our disposal,” said Chuck Rosenberg, Acting Administrator of the Drug Enforcement Administration in the release, confirming the interagency commitment to combat the nation’s drug problems.

Lesson 2: Home health remains under OIG’s microscope. A fair amount of the fraud involved home health and hospice cases, including the largest takedown in Florida. The charges suggest that indictments and scrutiny will continue under this Medicare mainstay. Keep abreast of the documentation changes, Federal Register releases, and new rules impacting home health to stay in the loop.

Lesson 3: Medicaid offenders beware. The Medicaid Fraud Control Units, in addition to cases brought by 31 state Attorneys General, focused on fraudsters intent on targeting the most vulnerable — the disabled, the elderly, and children. The offenses ranged from stealing funds to identity theft and everything else in between, and the financial charges were hefty.

Anticipate More Crackdowns In The Future

As the authorities go after more offenders and deliver steeper penalties with each iteration, it’s easy to predict that more criminal investigations under the False Claims Act and the Anti-Kickback Statute will ensue. You can expect a heightened fixation on civil cases under the Stark Law as well. With the monthly OIG Work Plan updates in full force and increased regulations coming down the pike, providers can’t be too careful and should prepare for the government’s healthcare fraud and abuse spotlight.

“Health care fraud is a reprehensible crime. It not only represents a theft from taxpayers who fund these vital programs, but impacts the millions of Americans who rely on Medicare and Medicaid,” said Daniel R. Levinson, Inspector General of the United States in DOJ release. “In the worst fraud cases, greed overpowers care, putting patients’ health at risk. OIG will continue to play a vital leadership role in the Medicare Fraud Strike Force to track down those who abuse important federal healthcare programs.”

Resources: To read the individual Takedown charges, visit www.justice.gov/opa/documents-and-resources-july-13-2017-national-health-care-fraud-takedown-press-conference.

Read the DOJ release at: www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-charges-against-over-412-individuals-responsible.