Health Care Fraud Takedown: DOJ Holds Medical Professionals Accountable

By Sheba Vine, JD, CPCO, VP & General Counsel, 1st Healthcare Compliance
Twitter: @1sthcc

The Department of Justice (DOJ), with assistance from the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) and several other law enforcement agencies, recently announced the results of its national health care fraud takedown. As the government continues to prioritize its efforts on combating health care fraud, it is prudent for health care providers to apply the same priority to mitigating risk in these areas.

The government’s latest action involved criminal charges against 601 individuals, which included 165 doctors, nurses and other licensed medical professionals, for their alleged participation in health care fraud schemes involving over $2 billion in fraudulent billings. Compare this to last year’s takedown that involved 412 health care professionals for $1.3 billion in health care fraud. Charged individuals allegedly participated in schemes to submit claims to federal health care programs (Medicare, Medicaid, TRICARE) and private insurance companies for medically unnecessary treatments, many of which were never provided. The DOJ noted that patient recruiters, beneficiaries and other co-conspirators were allegedly paid cash kickbacks in exchange for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare.

The DOJ ‘s efforts to hold individual wrongdoers accountable is more than evident this year. “The number of medical professionals charged is particularly significant, because virtually every health care fraud scheme requires a corrupt medical professional to be involved in order for Medicare or Medicaid to pay the fraudulent claims. Aggressively pursuing corrupt medical professionals not only has a deterrent effect on other medical professionals, but also ensures that their licenses can no longer be used to bilk the system.” In the past year alone HHS has excluded 2,700 individuals from participation in Federal health care programs.

According to HHS Deputy Inspector General Cantrell “[s]uch crimes threaten the vitally important Medicare and Medicaid programs and the beneficiaries they serve. Though we have made significant progress in our fight against health care fraud; our efforts are not complete. We will continue to work with our partners to protect the health and safety of millions of Americans.” In fact, last month the DOJ announced that it is hiring 311 prosecutors to increase resources and combat priority areas.

Going forward, an increase in health care fraud enforcement and prosecution efforts is to be expected. In light of this, health care providers need to be proactive in their compliance efforts with federal fraud waste and abuse laws, including the Anti-Kickback Statute, the Physician Self-Referral Law (also known as the Stark Law), and the False Claims Act. Maintaining an effective and robust compliance program is critical to avoiding and mitigating health care fraud.

This article was originally published on 1st Healthcare Compliance and is republished here with permission.