News Feature | January 23, 2014

Record Number Of Fraud Cases In 2013

Christine Kern

By Christine Kern, contributing writer

HITO Doctor In Cuffs

Changes brought about by the Affordable Care Act, revitalized efforts by the FBI and National Strike Force result in record number of fraud indictments in 2013

By Christine Kern, contributing writer

A record number of healthcare fraud cases were filed by federal prosecutors in 2013, apparently reflecting not necessarily a rise in crime, but rather a greater effort on the part of authorities to prosecute and ultimately prevent such fraud from occurring in the future.

In 2009, Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius partnered to create strike forces and allocate funds to target health care fraud. According to the FBI, “Healthcare fraud costs the country an estimated $80 billion a year. And it’s a rising threat, with national health care spending topping $2.7 trillion and expenses continuing to outpace inflation. Recent cases also show that medical professionals are more willing to risk patient harm in their schemes.” Through the funds allocated by Holder and Sebelius, in part, the FBI has focused on cracking down on such fraudulent schemes across the country, as evidenced by the rise in federal cases in 2013.

SFGate writes Medicare fraud has transformed “moving from medical equipment and HIV infusion fraud to ambulance scams as crooks try to stay a step ahead of authorities.” They are also far more sophisticated in their practices, often hiring “recruiters” to find patients, medical personnel, and company owners who are willing to be complicit in the ruse.

According to the National Health Care Anti-Fraud Association, most healthcare fraud is perpetrated by organized crime groups and can range from billing for services not rendered, to falsifying diagnoses to justify testing fees, to waiving copays and overbilling the insurance. Another common fraudulent practice is “unbundling,” or charging for each step of a procedure separately, which thus overcharges for the completed medical care. Such charges can be hard to detect with normal software programs.

One of the most successful strikes against healthcare fraud according to The Department of Justice occurred last May when 89 individuals in eight cities were indicted for fraud, to the tune of $223 million in false billings. This was the sixth nationally coordinated effort against Medicare fraud in the strike force’s history. In a press release, Sebelius stated: “The Affordable Care Act has given us additional tools to preserve Medicare and protect the tens of millions of Americans who rely on it each day.

“By expanding our authority to suspend Medicare payments and reimbursements when fraud is suspected, the law allows us to better preserve the system and save taxpayer dollars. Today we’re sending a strong, clear message to anyone seeking to defraud Medicare: You will get caught and you will pay the price. We will protect a sacred trust and an earned guarantee.” The chase is on.