Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

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Over 600 Individuals Charged in 2018 Healthcare Fraud Takedown

In the largest healthcare fraud takedown to date, OIG and DoJ reported charging individuals involved in fraud schemes that cost Medicaid and Medicare $2 billion.

Healthcare fraud

Source: Thinkstock

By Jacqueline LaPointe

- The HHS Office of the Inspector General (OIG) and Department of Justice (DoJ) recently announced the largest healthcare fraud takedown to date, with over 600 defendants charged with participating in fraud schemes amounting to about $2 billion in losses to Medicare and Medicaid.

Of the over 600 defendants charged, 165 were medical professionals, including 32 doctors who allegedly participated in healthcare fraud schemes involving prescribing and distributing opioids and other narcotics.

The charges jointly announced by the OIG and DoJ also involved claims submitted to Medicare, Medicaid, TRICARE, and private insurance companies for medically unnecessary prescription drugs that were oftentimes never purchased or given to patients.

The largest healthcare fraud takedown also resulted in multiple charges involving individuals playing a part in the opioid epidemic, the federal agencies highlighted. The agencies particularly focused on providers involved in the illegal distribution of opioids and other prescription narcotics.

“Health care fraud is a betrayal of vulnerable patients, and often it is theft from the taxpayer. In many cases, doctors, nurses, and pharmacists take advantage of people suffering from drug addiction in order to line their pockets. These are despicable crimes,” Attorney General Jeff Sessions stated in a DoJ press release.

“That’s why this Department of Justice has taken historic new steps to go after fraudsters, including hiring more prosecutors and leveraging the power of data analytics. Today the Department of Justice is announcing the largest health care fraud enforcement action in American history.  This is the most fraud, the most defendants, and the most doctors ever charged in a single operation—and we have evidence that our ongoing work has stopped or prevented billions of dollars’ worth of fraud.”

The OIG and DoJ have made announcing their healthcare fraud takedown totals from the past year a yearly event.

In 2016, the first year the federal agencies announced the healthcare fraud takedown, they reported charges against 301 individuals, including 61 physicians and other licensed medical professionals. That year, the healthcare fraud schemes involved $900 million in false medical billing.

The healthcare fraud and abuse investigations conducted by the OIG, DoJ, and other law enforcement partners have since captured more individuals involved in fraud schemes.

For example, in 2017, the federal agencies announced that their annual healthcare fraud takedown involved 400 charged individuals involved in healthcare fraud schemes totaling $1.3 billion in false or fraudulent billings to Medicare and Medicaid.

The annual healthcare fraud takedown tallies demonstrate the federal government’s commitment to combating fraud, waste, and abuse in public healthcare programs. And this year’s takedown particularly shows the government’s dedication to ending the opioid epidemic.

OIG noted in their announcement that, since last year’s takedown, the agency has issued exclusion notices to 587 physicians, nurses, and other providers for their roles in healthcare fraud schemes involving opioid diversion and abuse.

“This year’s operations, focusing on opioid-related schemes, spotlight the far-reaching impact of health care fraud,” said HHS Deputy Inspector General Gary Cantrell.  “Such crimes threaten the vitally important Medicare and Medicaid programs and the beneficiaries they serve.  Though we have made significant progress in our fight against health care fraud; our efforts are not complete.  We will continue to work with our partners to protect the health and safety of millions of Americans.”

Healthcare fraud crackdowns have not only been a top priority for the OIG and DoJ, but also CMS. The federal agency running Medicare and Medicaid has implemented several policies and programs in the past year to combat fraud, waste, and abuse.

Most recently, CMS announced in June 2018 that it plans to increase the number of Medicaid audits performed to prevent Medicaid fraud and improper payments.

The federal agency also extended a Medicare home health enrollment suspension in four states. The moratorium on Medicare enrollment aims to reduce the volume of inappropriate and fraudulent bills stemming from home health agencies in these high-risk states.

As the healthcare industry faces significant pressure to control the rising healthcare spending growth rate, the federal government is upping its efforts to reduce wasteful spending, particularly on false billings.

Providers should ensure their claims or behaviors are not targeted by healthcare fraud and abuse investigators by implementing comprehensive compliance programs and promptly addressing clinical documentation, coding, and billing issues occurring in their office.

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