Government Response to Losing Billions in Medicare and Medicaid Fraud

In response to the loss of tens of billions of dollars in Medicare and Medicaid funds to fraud, the federal government decided to step up the investigation and prosecution of health care fraud cases. In May 2009, the United States Department of Justice (DOJ) teamed up with the United States Department of Health & Human Services, Office of Inspector General (HHS OIG) to create HEAT. HEAT was formed to represent a shift from the “pay and chase” approach and work toward fraud prevention through the use of various powerful anti-fraud tools. Analysis teams use data to examine Medicare fraud claims looking for specific patterns, trends, and other evaluators in their investigations. In 2011, the Centers for Medicare & Medicaid Services (CMS) started using a fraud prevention system on all Medicare fee-for-service claims nationwide. This system uses technology similar to fraud detection technology used by credit card companies in looking for abnormal claim patterns for Medicare payments. This has resulted in nearly $1 billion in federal savings from these fraud detection and prevention techniques.

MEDICARE FRAUD STRIKE FORCE

An important part of HEAT is a task force known as the Medicare Fraud Strike Force. The Medicare Fraud Strike Force is an interagency group of analysts, investigators, and prosecutors who are from both the OIG and DOJ. This group investigates the latest fraud schemes and targets those whom they believe are fraudulently presenting themselves as legitimate health care providers or suppliers. The Medicare Fraud Strike Force has investigated and charged over 2,500 individuals for various forms of health care fraud. Since the inception of the Medicare Fraud Strike Force, they have maintained a 95% conviction rate along with an average prison sentence of more than four years. There is a Medicare Fraud Strike Force regional office in 10 cities nationwide:

• Detroit, MI
• Chicago, IL
• Miami, FL
• Los Angeles, CA
• Dallas, TX
• Houston, TX
• Brooklyn, NY
• Baton Rouge, LA
• New Orleans, LA
• Tampa, FL

It should be obvious at this point that the federal government is zeroed in on expanding efforts to combat suspected health care fraud now and in the foreseeable future.

HOW DOES THIS AFFECT ME?

If you are a healthcare provider or service that bills Medicaid or Medicare, then you might be at risk. As you have read above, the federal government has increased spending and focus on trying to prevent health care fraud. This trend will likely continue as the occurrence of health care fraud is unfortunately too common and much too lucrative for the federal government to ignore. In 2018, HHS reported that for every dollar the federal government spent on trying to combat healthcare fraud in the previous three years, the government recovered $4. It is easy to see why the federal government will likely continue to focus efforts on investigating and prosecuting cases of health care fraud. If you have any questions related to HEAT, the Medicare Fraud Strike Force, or potential health care fraud within your company, then it is important to speak to an experienced health care fraud attorney as soon as possible. The guidance may help you avoid criminal charges, or help you prepare your best defense in case you are charged. It is your responsibility to get answers to any questions you might have about the current practices within your health care business and if those practices are in legal compliance. Ignorance of the laws governing health care is not an excuse or legal justification to any alleged wrongdoing.