Reimbursement News

Dozens of Providers Charged in September Healthcare Fraud Busts

The Department of Justice and other agencies conducted several healthcare fraud takedowns last month and vowed to continue cracking down on healthcare crime.

Healthcare fraud

Source: Getty Images

By Jacqueline LaPointe

- Late last week, the Department of Justice (DoJ) charged 35 individuals, including ten medical professionals, for their involvement in a national healthcare fraud scheme that cost Medicare more than $2.1 billion.

According to the DoJ’s announcement, cancer genetic testing laboratories paid illegal kickbacks and bribes to medical professionals working with a telemarketing company for the referral of Medicare beneficiaries. The tests were oftentimes never provided or were medically unnecessary and providers generally prescribed the expensive cancer genetic tests without ever meeting patients face-to-face.

US Attorney Bobby L. Christine of the Southern District of Georgia called the case “unprecedented” and reassured the citizens of his community that the government’s response was equally exceptional, enabling law enforcement officials to stop the perpetrators.

However, the case is just one example of the healthcare fraud schemes DoJ and other law enforcement agencies took down in September.

Across the country, the Health Care Fraud Unit, HHS Office of the Inspector General, FBI, regional US Attorney Offices, and other agencies had a busy month charging providers and other individuals for their involvement in healthcare fraud schemes that defrauded Medicaid and Medicare out of billions of dollars.

READ MORE: How Providers Can Detect, Prevent Healthcare Fraud and Abuse

The following breaks down some of the recent healthcare fraud takedowns that implicated dozens of providers for their potential involvement in fraudulent billing, “pill mill” clinics, illegal kickback payments, and other healthcare crimes.

Midwest healthcare fraud takedown

Law enforcement authorities charged 53 individuals in Detroit, Chicago, and Minnesota over separate Medicaid and Medicare fraud schemes, the DoJ reported last week.

Specifically, the authorities charged 20 individuals in the Eastern District of Michigan for their alleged participation in Medicare fraud schemes that led to nearly $145 million in illegitimate billings. Medicare fraud was also at the center of cases involving 12 individuals, including seven physicians or licensed medical professionals, in the Northern District of Illinois. Authorities charged the individuals over their possible involvement in $103 million in fraudulent billing.

In the state of Minnesota, authorities charged two licensed medical professionals and 19 other individuals for defrauding Medicaid. The individuals allegedly conned the public healthcare program out of almost $3 million.

DoJ stated that the charges announced in the Midwest “aggressively” targeted plots to bill Medicare, Medicaid, and private payers for medically unnecessary services, medical procedures that never occurred, and prescription medications that were oftentimes never purchased or given to patients.

READ MORE: 13 States Still Struggle to Check Providers to Avoid Medicaid Fraud

“Health care fraud robs taxpaying Americans and corrupts the relationship between doctors and patients,” stated Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division.  “Today’s actions in the Midwest are further proof of the Department’s steadfast commitment to investigating and prosecuting those who put their personal greed above the public good.”

48 charged in Northeastern healthcare fraud bust

DoJ announced on Sept. 26 the takedown of “pill mill” clinics in the Northeast that involved more than $800 million in loss and the distribution of over 3.25 million opioid pills.

Federal and state law enforcement officials charged 48 individuals, including 15 healthcare providers, across seven federal districts in the Northeast for potentially submitting over $160 million in fraudulent claims. Twenty-four individuals were also charged for their roles in diverting opioids.

The Sept. 26 press release also announced the guilty pleas of three corporate executives, including the vice president of marketing of several telemedicine companies and two owners of approximately 25 durable medical equipment companies. The executives admitted to their roles in healthcare fraud schemes that submitted over $600 million in fraudulent claims to Medicare.

The charges and guilty pleas in the Northeast home in on corporate healthcare fraud and fraudulent telemedicine companies, DoJ stated. The cases highlight the use of illegal kickbacks and bribes paid by companies to healthcare suppliers and providers for medical unnecessary services and items.

READ MORE: OIG Releases Healthcare Fraud Compliance Program Guidelines

The cases also stress the prevalence of the opioid epidemic and the role healthcare providers can play in exacerbating the issue, which kills approximately 115 Americans each day, DoJ emphasized in the announcement.

Gulf Coast sees influx of healthcare fraud cases

The Gulf Coast was not immune to healthcare fraud last month. In a recent announcement, DoJ reported healthcare fraud schemes that aimed to defraud Medicare, Medicaid, and TRICARE, as well as to acquire oxycodone and other controlled substances.

Eleven individuals were charged for their potential roles in the healthcare fraud schemes, which result in more than $515 million in fraudulent billing. The individuals charged included physicians, licensed social workers, as well as other medical and business professionals, DoJ emphasized.

The same day as the announcement, the federal department also reported the charging of 67 individuals allegedly involved in a healthcare fraud ring across Florida and Georgia. The charges stated that the individuals, including several healthcare professionals and physicians, defrauded Medicare and Medicaid of more than $160 million over medically unnecessary care.

Sixteen individuals in the state of Florida will also face a judge over accusations that they falsely billed Medicaid for over $1.2 million for medically unnecessary services.

DoJ pointed out that the charges announced in Florida and Georgia included services that were not medically necessary, such as home health, prescription drugs, and durable medical equipment.

Medicaid, Medicare fraud on the West Coast

Federal and state officials recently cracked down on several Medicare and Medicaid fraud schemes across the West Coast, according to a Sept. 18 announcement from the DoJ.

In California, DoJ’s Criminal Division announced a healthcare fraud enforcement action involving charges against 26 individuals for their potential participation in Medicare and Medicaid fraud schemes that led to $257 million in fraudulent bills. Of those charged, 14 were physicians or medical professionals, DoJ reported.

Law enforcement officials also nabbed three licensed medical professionals and eight other individuals in Arizona and Oregon for their alleged involvement in a $1 million Medicare fraud scheme.

In all three states, the healthcare fraud schemes centered on fraudulent Medicare and Medicaid billing schemes in which services, testing, and prescriptions were either not medically necessary or were not actually provided to patients, DoJ reported.

Healthcare fraud is currently a top priority of DoJ and other federal and state law enforcement agencies, the announcement stated. Federal and state officials are aggressively pursuing instances of healthcare fraud using any means possible.

“Today’s action shows that our ability to detect and prosecute health care fraud grows more sophisticated with each passing day,” stated Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division. “The Department of Justice is using every tool at our disposal to target the medical professionals and others who place their personal greed above the public good.”