On June 28, 2023, the Justice Department, together with federal and state law enforcement partners, announced a strategically coordinated, two-week nationwide law enforcement action that resulted in criminal charges against 78 defendants for their alleged participation in healthcare fraud and opioid abuse schemes that included over $2.5 billion in alleged fraud.
The defendants allegedly defrauded programs entrusted for the care of the elderly and disabled, and, in some cases, used the proceeds of the schemes to purchase luxury items, including exotic automobiles, jewelry, and yachts. In connection with the enforcement action, the Department seized or restrained millions of dollars in cash, automobiles, and real estate.
The telemedicine fraud enforcement action included charges against 11 defendants in connection with the submission of over $2 billion in fraudulent claims resulting from telemedicine schemes. The pharmaceutical fraud enforcement action included charges against 10 defendants in connection with the submission of over $370 million in fraudulent claims submitted in connection with prescription drugs.
The charges also targeted over $150 million in false billings submitted in connection with other types of healthcare fraud, including the illegal distribution of opioids and clinical laboratory testing fraud. The enforcement action includes charges against 24 physicians and other licensed medical professionals who lined their own pockets, including doctors who allegedly put their patients at risk by illegally providing them with opioids they did not need. The charges also include cases where healthcare companies, physicians, and other providers paid cash kickbacks to patient recruiters and beneficiaries in return for patient information, so that the providers could submit fraudulent bills for Medicare reimbursement.
“These enforcement actions, including against one of the largest healthcare fraud schemes ever prosecuted by the Justice Department, represent our intensified efforts to combat fraud and prosecute the individuals who profit from it,” said Attorney General Merrick B. Garland. “The Justice Department will find and bring to justice criminals who seek to defraud Americans and steal from taxpayer-funded programs.”
The Center for Program Integrity of the Centers for Medicare & Medicaid Services (CPI/CMS) separately announced on June 28 that it took adverse administrative actions in the last six months against 90 medical providers for their alleged involvement in healthcare fraud.
Access the press release here.
Descriptions of cases involved in the enforcement action are available 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.*
