Health Care Fraud 101

August 1, 2017

Stethoscope, handcuffs and money on grayBy: Sara Kropf

On July 13, 2017, the Department of Justice issued a press release touting “the largest ever health care fraud enforcement action by the Medicare Fraud Strike Force.”

Most likely, none of these case will be particularly complex. DOJ loves to coordinate a lot of arrests on one day so that it can issue these press releases to show that it is tough on crime.

Usually these take-downs charge only the classic “low lying fruit”–individuals and small companies engaged in the most obvious fraud.

Because DOJ focuses on the obvious wrongdoers, the stats are impressive on their face. DOJ charged 412 defendants, including 115 doctors, nurses and “other licensed medical professionals.” The supposed fraud schemes involved approximately $1.3 billion in false billings.

A few things are clear from this effort:

  1. DOJ remains focused on charging individuals
  2. The opioid crisis is resulting in a lot of criminal charges, as 120 defendants were charged for their role in prescribing and distributing these drugs.
  3. DOJ is working closely with state regulators–30 state Medicare Fraud Control Units participated in the arrests.

Health care fraud remains a focus of DOJ, as it struggles to figure out its identify under Attorney General Sessions. The most recent effort targets certain health care fraud, such as Medicare billing misconduct and illegal kickbacks. From the press release:

According to court documents, the defendants [in the July 13, 2017 take-down] allegedly participated in schemes to submit claims to Medicare, Medicaid and TRICARE for treatments that were medically unnecessary and often never provided. In many cases, patient recruiters, beneficiaries and other co-conspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare for services that were medically unnecessary or never performed. 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.

My Series of Blog Posts on the Basics of Health Care Fraud

For the past few months, I’ve written a series of short blog posts on health care fraud for a great online newsletter called Physicians Practice. The posts are targeted for the lay reader–not for you fancy-pants lawyers out there. But if you need a quick refresher on health care fraud or want to understand the basics of defending against these claims, I’ve linked to the posts below. (Note: you may need to sign up for the free newsletter to read the posts.)

Healthcare Fraud 101: An Overview of the Key Statutes

This post outlines the four main statutes used by the federal government to fight health care fraud: False Claims Act, Stark Law, Anti-Kickback Statute and the mail/wire fraud statutes. It’s an overview for the rest of the posts in the series.

Healthcare Fraud 101: The False Claims Act

This post covers what kinds of conduct the civil False Claims Act prohibits, the range of penalties that can be imposed for violating it and the unique procedure for bringing a claim under it, including how the whistle-blower provisions work.

Healthcare Fraud 101: What To Do If You Learn You Are Under Investigation for Violating the False Claims Act

This post covers what to do if you learn that the government is investigating your practice for alleged false claims. It describes how you may learn about an investigation, what the first steps should be to respond to the investigation and why an internal investigation may help protect your practice in the end. It also explains the practical steps a health care provider can take to defend against a possible FCA lawsuit.

Healthcare Fraud 101: Getting a Subpoena

Getting a subpoena is a scary moment for any defendant. This post describes what steps to take when you receive a subpoena, both to respond to the subpoena and prevent any allegations of obstruction of justice.

Healthcare Fraud 101: 9 Gifts That Violate the Anti-Kickback Statute

This post provides an overview of the Anti-Kickback Statute’s provisions, including the safe harbors and penalties for violating it. It then describes some of the most common ways that health care providers violate it.

Healthcare Fraud 101: Criminal Enforcement Trends

Predicting what DOJ will do in the future is risky business, but I pull out my crystal ball in the health care arena. I describe a few future enforcement trends, including DOJ’s use of data analytics to identify illegal billing practices.

Published by Kropf Moseley

Whether you need to take a case to trial, negotiate a resolution without ever setting foot in the courtroom, or navigate a complex public relations problem, we can help. View all posts by Kropf Moseley.