HHS, Justice Department Make Major Fraud Bust

The Department of Justice (DOJ) busted 94 people July 16 for their alleged participation in schemes to collectively submit more than $251 million in false claims to the Medicare program in the continuing operation of the Medicare Fraud Strike Force in Miami; Baton Rouge, La.; Brooklyn, N.Y.; Detroit and Houston, announced Attorney General Eric Holder, Department of Health and Human Services (HHS) Secretary Kathleen Sebelius, FBI Director Robert Mueller and Daniel R. Levinson, Inspector General of HHS. The operation is the largest federal health care fraud takedown since Medicare Fraud Strike Force operations began in 2007.

The joint DOJ-HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing. More than 360 law enforcement agents from the FBI, HHS-Office of Inspector General (HHS-OIG), multiple Medicaid Fraud Control Units, and other state and local law enforcement agencies participated in the operation.

Certified Professional Medical Auditor

The 94  individuals  are accused of various Medicare fraud-related offenses, including conspiracy to defraud the Medicare program, criminal false claims, violations of the anti-kickback statutes and money laundering. The charges are based on a variety of fraud schemes, including physical therapy and occupational therapy schemes, home health care schemes, HIV infusion fraud schemes and durable medical equipment (DME) schemes. Thirty-six defendants charged in these schemes were arrested in Miami, New York, Baton Rouge and Detroit and additional arrests are expected throughout the day.

According to the court documents, the defendants charged participated in schemes to submit claims to Medicare for treatments that were medically unnecessary and oftentimes, never provided. In many cases, indictments and complaints allege that beneficiaries accepted cash kickbacks in return for allowing providers to submit forms saying they had received the treatments that, in reality, were unnecessary or never provided. Collectively, the doctors, health care company owners, executives and others charged in the indictments and complaints are accused of conspiring to submit more than $251 million in false claims to the Medicare program.

In Miami, 24 defendants were charged for allegedly participating in various fraud schemes that led to approximately $103 million in false billings. According to court documents, the fraud schemes involved fraudulent billing for HIV infusion services, home health care and physical therapy services, DME and pharmaceutical medications. The defendants include owners and operators of companies, doctors, nurses, and patient recruiters, as well as a medical biller who is alleged to have billed approximately $49 million for fraudulent services.

Thirty-one defendants were charged in Baton Rouge for various schemes allegedly involving fraudulent claims for DME totaling approximately $32 million. The defendants include the owners and operators of nine different purported medical services companies and four doctors, 14 patient recruiters and other individuals who allegedly worked at the medical services companies.

Twenty-two defendants were charged in Brooklyn for their alleged participation in schemes to submit fraudulent claims totaling approximately $78 million. These fraud schemes involved false billing for physical and occupational therapy and DME. The defendants include the owners and operators, patient recruiters and employees at three different purported medical clinics and a medical equipment company, as well as three doctors. According to court documents, six of the defendants charged are serial Medicare beneficiaries, who purported to seek medical treatment from numerous providers, causing the submission of multiple claims to Medicare for purported medical treatments.

In Detroit, 11 defendants were charged for their alleged roles in schemes to submit fraudulent claims to Medicare for home health services, nerve conduction tests and injection and infusion therapy sessions. The schemes involved a total alleged fraud of approximately $35 million and five different purported medical services companies.

Four defendants were also charged in Houston for their alleged roles in a $3 million scheme to submit fraudulent claims for DME.

In addition to making arrests around the country, law enforcement agents executed search warrants in connection with ongoing health care fraud investigations.

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20 Responses to “HHS, Justice Department Make Major Fraud Bust”

  1. Barbara says:

    I am a healthcare fraud investigator for a major commercial health insurance company. How can I find out the names of the Providers involved so we can see if our company was affected?

  2. Jill says:

    I feel you should do your own work, instead of asking someone else who has already did the work to give you names. I am sure your insurance company is one that denies clean claims and is hard to get payment from. I would report Fraud if I saw it, but I would not, If I was HHS give you any names when they have done all the work.

  3. M says:

    Jill, what an idiotic response. What you’re basically saying is that insurance companies (public and private) deserve to be ripped off, which means the members/patients get ripped off as well, which means higher costs for everyone. You don’t need to be working in a healthcare setting.

  4. Susan Says: says:

    I would like to know the providers names too. I think that this should be public knowledge. BTW, I agree with M. What are you thinking, Jill and is English your first language?

  5. C. Proctor says:

    http://stopmedicarefraud.gov provide providers names for indictments and convictions.

  6. Linda B. NCMC says:

    Fraud is fraud! Provide providers names to assist in eradicating fraud, then if you have an issue with insurance companies denying clean claims, take it up with the Commissioner of Insurers in the state you reside. Those of us who have chosen Coding, and HIM as a part of our lives should do everything we can to assure our profession maintains the highest level of respect and professionalism; this includes taking appropriate measures with all sources we are associated with…. HIPAA!

  7. Larry L. says:

    Fraud is a growing problem that as Linda referred to could be curbed if the names were made public. Loss of assets, career, fines, and jail time is not enough. Public humiliation needs to be included so everyone can know who the criminals are. Jill your logic is ridiculous and I agree you shouldn’t be allowed near a healthcare setting let alone a claim or insurance company.

  8. Steven L says:

    I have worked for the Attorney General in our state. I would like to know the names of all practitioners involved in this scheme. I currently work for a Commercial Insurance company and want to open up an investigation on this scheme. If this scheme worked in Florida I am sure it will work in other states under other names and Provider ID’s. 251 million in false claims is a very large network of participants, providers, clinics, companies etc.

  9. Kollette says:

    I agree that the names should be published and I’m not even a certified coder yet. I am only out of school by 4 months and in school, something that is consistently taught is the coders obligation to report fraud and to get more information if they feel their providers have billed incorrectly. To be honest, I have a terrible memory and I am second-guessing my career choice now because I am very afraid that a simple mistake on my part could lead to a fraud claim. Fraud such as this makes coders jobs a whole lot harder because it causes unnnecessary scrutiny from companies in order to catch fraudulent claims, therefore those coders who always submit clean claims and make one minor mistake could be investigated for fraud. So, yes the names should be submitted, but only after a thorough investigation that the coder was actually “involved” and wasn’t just trusting their providers.

  10. Gina P says:

    I beleive you should be able to get that information from the OIG but only after the convictions are made.

  11. Lisa says:

    I find all the comments that i have read VERY interesting. I am seriously considering a career in coding. Evreryone of you have made valid points with the exception of JILL!! Jill why have you chosen this field to begin with?

    Kollette, a “simple” mistake is a “mistake” I don’t think you will be investigated unless you consistantly have errors and you give them reason to investigate.

    I think names should be given. Fraud is WRONG!! How people think they can get away with it is… crazy!! you maybe able to get away maybe for a little while but eventually, you will be found out!! Sad and so very true that people are full of GREED and are SELFISHNESS these days. You deserve everything you get!!!

    NAMES PLEASE!!

  12. Debby Herbert says:

    For Kollette, as part of your coding studies you need to check out what exactly is the definition of fraud and what is the definition of abusive coding practices. This is part of HIPAA. I think if you do, you will see that making a coding mistake constitutes neither.

  13. Smartypants says:

    You are the one who was hired as a “healthcare fraud investigator”. You should be the expert telling us how to find names from a major Medicare fraud investigation, not posting questions hoping some coder out there knows your job better than you. Sounds like you need to be demoted into a position less taxing on your feeble mind.

  14. Yvonne Worosylla says:

    I would imagine that this fraud is also what has impacted the need for CBR reporting that has just been handed down here in September. 5,000.00 Therapist were the first target.

    This makes things so bad for people who treat and love what they do to get people well and people that need the help… damn people with their fraud in any entity!! This takes away from people that need to get better!!

  15. Shobha Sharma says:

    Verify the use of codes to actual services provided in patient-provider visit reflecting clinical documentation of services provided in medical record does not constitute to activities related to fraud.

    However, code used and reimbursed as primary code must have supporting documentation.

    Attention to accurate coding is a must, which may not lead to denial of claims or recover the monies reimbursed – Well I think coder, provider, health facility owner/administrator share accountability and accuracy in billing of services provided!!

  16. Meegan says:

    Someone in my family is in this area of investigation with the FBI. I already told him, Orange is not my color. You won’t find me as one of your suspects. How do these people call themselves coders?!

  17. Gwen says:

    Susan, while I agree that Jill’s response wasn’t one we agree with, but what ON EARTH does that have to do with being a native English speaker?

  18. Smartypants says:

    Gwen Says: “Susan, while I agree that Jill’s response wasn’t one we agree with, but what ON EARTH does that have to do with being a native English speaker?”

    -that’s easy…it was a slam against Jill’s poor grammer. Any other questions from the peanut gallery ?

  19. sharonrose says:

    I agree with Gwen…we are professionals and lets conduct our open forums in a professional manner, while we can certainly ‘respectfully disagree’ with someone, we don’t need to sling mud and make personal attacks on anything outside our coding forum.

  20. Bren says:

    I am late in seeing this article (trying to catch up on my CEUs :)) I work at a large insurance carrier taking provider calls. We have been stating for years something is up with the DME providers. They never have an ID # for the member, they bill claims with the dates of service overlapping another DME provider for the same item and unless the member is saavy, they will pay the charges these DME companies bills them without question. The worst offenders seem to be diabetic supplies. It is often the frontline who sees this but of course, we are ignored. As long as they can provide HIPAA information on the member and they have an NPI, we give them the benefits they ask for and pay their claims.

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