If You Can’t Take the HEAT…

By: John Avicolli, CIS Senior Compliance Associate
johnavicolli@cis-partners.com

Fact – “Three HealthEast Care System hospitals have agreed to pay the United States $2.28 million to settle allegations that the health care facilities submitted false claims to Medicare.”[1]

Fact – “Regency Nursing and Rehabilitation Centers Inc. nursing home chain will pay the United States $4 million to settle allegations that Regency submitted false claims to Medicare and the Texas Medicaid program.”[2]

Fact – “Executives and employees at WellCare Health Plans Inc. engaged in an elaborate scheme to defraud the Florida Medicaid program and the Florida Healthy Kids Corporation. In order to avoid a health care fraud conviction on these charges WellCare must, among other things, consent to the civil forfeiture of $40,000,000 and pay an additional $40,000,000 in restitution to the Florida Medicaid and Healthy Kids programs to repay proceeds from those programs to which WellCare was not entitled.”[3]

Medicare fraud cases cost taxpayers billions of dollars. Fraud scams run the gamut from phantom billing, performing unnecessary procedures, and providing substandard care then seeking Medicare reimbursement, to offering free services in exchange for Medicare or Medicaid number. These instances illustrate a few of the devious ways health care fraud perpetrators are stealing billions of dollars from the federal government and, ultimately, crippling the long term solvency of the Medicare and Medicaid programs.

In an effort to combat the mounting number of fraud cases, Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius recently announced the creation of a new interagency effort, the Heath Care Fraud Prevention and Enforcement Action Team, which will be known as “HEAT.” Additionally, they announced the expansion of Medicare Fraud Strike Force (MFSF) team operations, already being run in Los Angeles and South Florida, to Detroit and Houston. The MFSF team in South Florida with enjoyed measured results; it has already convicted 146 defendants and secured $186 million in criminal fines and civil recoveries.

“The HEAT team will include senior officials from the Department of Justice (DOJ) and HHS who will build upon and strengthen existing programs to combat fraud while also investing new resources and technology to prevent fraud, waste and abuse before it happens,” reported HHS.[4] HEAT and MFSF utilize a “data-driven” approach to identify unexplainable billing patterns with respect to investigating fraudulent activity. Part of this data driven approach is steeped in examining claims and identifying facilities that appear to be producing more claims than would be expected, given the demographic makeup of a surrounding area.

Although recouping millions of dollars in fraudulent billings is a primary concern for HEAT, there is a significant emphasis placed on prevention and ensuring front end compliance within the system. HEAT is committed to “improving data sharing between the Centers for Medicare & Medicaid Services and law enforcement so additional patterns that lead to fraud can be exposed,” “strengthening program integrity activities to monitor and ensure compliance,” and “increasing training for providers on Medicare compliance and supplying the knowledge and resources for providers to identify and prevent fraud.”[5]

Sources:
[1] http://www.usdoj.gov/opa/pr/2009/May/09-civ-497.html
[2] http://www.usdoj.gov/opa/pr/2009/May/09-civ-498.html
[3] http://medicare-fraud.net
[4] http://www.hhs.gov/news/press/2009pres/05/20090520a.html
[5] http://www.hhs.gov/news/press/2009pres/05/20090520a.html