On June 27, 2024, the Justice Department announced the results of their 2024 National Health Care Fraud Enforcement Action. This initiative led to criminal charges against 193 defendants, including 76 doctors, nurse practitioners, and other licensed medical professionals in 32 federal districts across the United States. These individuals were allegedly involved in various healthcare fraud schemes resulting in approximately $2.75 billion in intended losses and $1.6 billion in actual losses. As part of the coordinated nationwide effort, and together with federal and state law enforcement partners, the government seized over $231 million in cash, luxury vehicles, gold, and other assets.
The charges alleged include an over $900 million fraud scheme committed in connection with amniotic wound grafts, the unlawful distribution of millions of pills of Adderall and other stimulants by five defendants associated with a digital technology company, an over $90 million fraud committed by corporate executives distributing adulterated and misbranded HIV medication, over $146 million in fraudulent addiction treatment schemes, over $1.1 billion in telemedicine and laboratory fraud, and over $450 million in other healthcare fraud and opioid schemes.
The Justice Department said that their efforts to combat healthcare fraud are focused on four fundamental principles:
- Protecting vulnerable patients
- Defending taxpayer-funded programs
- Ensuring full accountability by prosecuting the perpetrators of these crimes and seizing their criminal proceeds
- Using data analytics to keep pace with constantly evolving fraud schemes
“Healthcare fraud affects every American,” said Principal Deputy Assistant Attorney General Nicole M. Argentieri, head of the Justice Department’s Criminal Division. “It siphons off hard-earned tax dollars meant to provide care for the vulnerable and disabled. In doing so, it also raises the cost of care for all patients. Even worse, as the prosecutions we announce today underscore, healthcare fraud can harm patients and fuel addiction. The Criminal Division is committed to rooting out healthcare fraud, wherever it may be found, no matter who commits it. And we are using more tools than ever before to uncover misconduct and hold wrongdoers to account, whether they are executives in corner offices or doctors who violate their oaths.”
Access the press release here.
Compliance Perspective
Issue
Healthcare fraud affects everyone—individuals and businesses alike—and causes tens of billions of dollars in losses each year. It can raise health insurance premiums, expose individuals to unnecessary medical procedures, and increase taxes. Healthcare fraud can be committed by medical providers, company owners, patients, and others who intentionally deceive the healthcare system to receive unlawful benefits or payments. All staff who provide skilled services must understand what constitutes reasonable and necessary skilled services. The skilled services must be based upon a patient’s ability, need, and what is reasonable for the patient. Staff should be knowledgeable and aware of what may be considered a false claim. Failure to promptly report suspected fraud can result in citations, fines, and other sanctions. In addition, staff should be knowledgeable in how to report suspicious billing practices.
Discussion Points
- Review policies and procedures for preventing and reporting false claims and suspicious billing practices. Update your policies and procedures as needed.
- Train all staff on what can be considered a false claim or kickback. Include information on how to report concerns and suspected violations, and that prompt reporting is mandatory. Document that the trainings occurred and place in each employee’s education file.
- Periodically perform audits to ensure all staff are aware of their responsibility to identify compliance and ethics concerns and to promptly report violations to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Perform Triple Checks for all Medicare Part A claims prior to submission to ensure that medical necessity is supported by appropriate documentation, and that services meet skilled care requirements.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
