Health Care Fraud Blog

U.S. Senator Tom Coburn of Oklahoma, who is also a medical doctor, is proposing that the United States root out Medicare Fraud through the use of undercover patients. Actually this is not new a new idea, government agents have in the past used undercover activities for precisely this purpose; recently, undercover agents posing as patients have been used extensively for investigations of pain management clinics.

Part of the problem is that often the undercover agent has to come up with a malady that would be the pretense of the visit. Generally, undercover agents posing as patients generate a false identity as well as a false medical history; sometimes going as far as to use test results, x-rays or the like from other, real patients. Sometimes, for example with pain clinics, the condition could be somewhat subjective; “My back hurts.” Such investigations can have good, bad and sometimes even funny results. In one undercover investigation, a Medicaid fraud agent, posing as a patient going to physician’s offices where it was alleged patients were paid, learned that one of the physicians he went to see diagnosed him with, among other things, erectile dysfunction. On the not so funny side, one department of insurance agent investigating chiropractors posed as a patient and wound up receiving an adjustment that injured his back.

In the Medicare arena, since the program is for persons over 65, the challenge would be to use retired or near retired agents and then address the same quandary; do you falsify conditions or symptoms? This can be more difficult to do with an older agent/patient; some conditions or diagnoses that might lend to potential fraudulent activity by physicians such as cancer and cardiac conditions are difficult to fake. Although scenarios can always be found to avoid a circumstance where a patient will receive certain treatments or injections, sometimes the outcomes are hard to determine.

To read more, click here.

The FY 2011 Budget requests a $234.6 million increase, including 708 new positions (143 agents and 157 attorneys), to restore confidence in U.S.markets, protect the federal treasury and defend the interests of the U.S. Government.

This includes an additional $96.8 million for economic fraud enforcement, which is a 23 percent increase over the FY 2010 level. This increase will continue the department’s efforts to aggressively pursue traditional law enforcement and litigation activities ranging from mortgage fraud, corporate fraud and other economic crimes, to other mission-critical activities that support the overall functioning and efficiency of the department.

The Department of Health and Human Services’ (HHS) budget requests a $60.2 million increase specifically for DOJ components involved in the investigation and litigation of health care fraud cases. This increase will further the efforts of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced last year by Attorney General Holder and HHS Secretary Kathleen Sebelius.

DOJ's efforts to combat health care fraud are funded almost exclusively through reimbursements from the Health Care Fraud and Abuse Control (HCFAC) account administered by the Department of Health and Human Services (HHS). In FY 2010, the HCFAC account provided $211.4 million in mandatory and discretionary funding for the DOJ litigating components and the FBI which are engaged in combating health care fraud. The increased funding will permit DOJ to expand Medicare Fraud Strike Force operations in order to target agents and attorneys to the criminal hubs where health care fraud activities occur. In addition, these funds will be used for civil enforcement efforts, including alleged fraud by pharmaceutical and medical device manufacturers. These anti-fraud efforts have the potential to save $2.7 billion over five years by improving oversight and stopping fraud in the Medicare and Medicaid programs.

For more information, click here to view the Restore Confidence in our Markets, Protect the Federal Fisc, and Defend the Interests of the United States Fact Sheet.

Recently state and federal authorities announced a regional health care fraud strike force in the Tampa and Orlando region. In what may be one of the first operations of that strike force, a Lakeland, Florida couple, Lilian Pagkaliwangan, 40, and Raymundo P. Arellano, 42, operators of Lakeland Therapy Providers Inc. and Optimum Therapy Inc., were arrested for health care fraud with respect to the operation of those businesses. The charges include alleged fraudulent billing for services not provided.

According to the indictment the couple submitted claims for reimbursement for medical services not rendered, including services that were claimed to have been provided on days when the patients were not present at the clinic and couldn't receive services.

Click here to read more.

According to a report released this earlier this morning, hours ahead of an official announcement scheduled for later today, arrests were made in Miami, Brooklyn and Detroit. Federal agents are expected to take about 30 suspects into custody from three states on charges related to Medicare fraud totaling $61 million.

The arrests follow an investigation by the Medicare Fraud Strike Force, a partnership between the two federal agencies that started nationally in May. Click here to read an earlier blog post.

According to sources speaking on the condition of anonymity, HHS Secretary Kathleen Sebelius will hold a news conference this afternoon in New York to make the announcement of the government’s continued crackdown on Medicare fraud. A key part of President Barack Obama's proposed healthcare overhaul targets eradicating an estimated $60 billion a year lost to Medicare fraud.

Today’s raids come a week after HHS reported that in 2008 Miami-Dade County received more than $500M from Medicare in home healthcare payments intended for the sickest patients. This figure is more than the rest of the country combined. To read the OIG report, click here.

Indictments are expected to charge that Florida scammers arranged for fake patients to bill for home healthcare, including homeless patients and others fraudulently listed as blind diabetics who submitted bills for visits by nurses twice-daily to give them insulin injections. See this Miami Herald video.

In Detroit, suspects paid recruiters to find patients willing to fake symptoms in order to justify expensive testing, and in turn bill Medicare for reimbursement. Two Brooklyn suspects are alleged to have billed Medicare for medically unnecessary durable medical equipment (DME), including expensive shoe inserts reserved for diabetics.

Increasingly the manner in which the government promotes its law enforcement efforts in the Medicare arena sound more and more like military operations or even Saturday morning cartoons. The creation of the “Strike Force” known as HEAT, Health Care Fraud Prevention & Enforcement Action Team, sounds a lot more like commandos than lawyers and agents arresting doctors and white collar criminals. In the press releases you see the use of the words “combat” and “battle” and now the battle also has phases: Miami (Phase One), Los Angeles (Phase Two), Detroit (Phase Three), and Houston (Phase Four).

For more, click here.

According to Senator LeMieux of Florida, Florida is the health care fraud capital of the world and instead of reforming health care, the government should be focusing on fixing the current system, particularly targeting fraud waste and abuse.

Meanwhile, federal authorities are using South Florida as the testing site for the health care fraud initiatives given the prevalence of health care fraud in Dade, Broward and Palm Beach counties. The Obama administration has asked for $300 million to combat health care fraud in 2010.

To view his speech on the Senate floor in this video.

To read more, click here.

WASHINGTON (November 17, 2009) — Today President Barack Obama established by Executive Order an interagency Financial Fraud Enforcement Task Force (FFETF) to strengthen efforts to combat financial crime. According to a press release, the Department of Justice will lead the task force and the Department of Treasury, HUD and the SEC will serve on the steering committee. The task force's leadership, along with representatives from a broad range of federal agencies, regulatory authorities and inspectors general, will work with state and local partners to investigate and prosecute significant financial crimes, ensure just and effective punishment for those who perpetrate financial crimes, address discrimination in the lending and financial markets and recover proceeds for victims.

To read the press release in its entirety, click here.