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Sebelius: New Fraud Prevention Team will Turn up Heat

Ben Amirault, May 21, 2009

Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius announced this week the government's latest tool in the fight against healthcare fraud and abuse—The Health Care Fraud Prevention and Enforcement Action Team (HEAT).

With what appears to be an intended pun, Sebelius said, "Today, we are turning up the heat on perpetrators who steal from the taxpayers and threaten the future of Medicare and Medicaid."

The HEAT team will consist of senior Department of Justice and HHS employees. Their task will be to strengthen existing fraud prevention tools and investigate new ways to root out and prevent fraud, which, according to Office of Inspector General Chief Counsel Lewis Morris, accounts for about 3%—or more than $60 billion—of the government's annual healthcare investment.

The team will build on demonstration projects created by the HHS Inspector General and the Centers for Medicare & Medicaid Services that focus on the vulnerable durable medical equipment (DME) industry. This includes:

  • Increasing site visits to potential suppliers to prevent imposters from posing as legitimate DME providers
  • Increasing training for providers on Medicare compliance, and offering providers the resources and the knowledge they need to help identify and prevent fraud
  • Improving data sharing between CMS and law enforcement to identify patterns that lead to fraud
  • Strengthening program integrity activities to monitor and ensure Medicare Parts C (Medicare Advantage plans) and D (prescription drug programs) compliance and enforcement

Holder and Sebelius also announced the expansion of the Medicare Fraud Strike Forces. Since their inception in 2007, the Medicare Fraud Strike Forces have recovered more than $240 million in fraud and abuse cases in South Florida and Los Angeles. The targets for the latest expansion are Detroit and Houston.

The creation of the HEAT team, the expansion of the Medicare Fraud Strike Forces, and the creation of a new healthcare fraud hotline (www.hhs.gov/stopmedicarefraud or 1-800-HHS-TIPS) continue President Barack Obama's push for greater healthcare fraud enforcement. Obama has made strengthening the integrity of the Medicare and Medicaid programs a priority for 2010, allotting $311 million of the $3.4 trillion budget on healthcare fraud and abuse prevention.

Also on Wednesday, Sen. Arlen Specter (D-PA), as the new chair of the Senate Judiciary's Crime and Drugs Subcommittee, presided over a hearing on whether tougher criminal sanctions should be used to serve as a deterrent to healthcare fraud.

"A greater investment in enforcement will pay sizeable dividends," said Lanny Breuer, an assistant attorney general in Justice's criminal division, who testified before the panel.

He noted that in South Florida, the Justice Department's prosecutions in fraud cases have had a "clear deterrent effect": In South Florida, for instance, the work of the Medicare Fraud Strike Force has led to a $1.75 billion reduction in DME claim submissions and $334 DME claims paid by Medicare in the past 12 months.

Current antifraud efforts have represented about a $4 return to the Medicare Trust Fund for every $1 dollar spent, Breuer said.

One of the big lessons that Justice Department officials have learned is "that quick apprehension and punishment of these criminals is critical."

Some of the more high-profile cases handled were conviction of a Miami physician in an $11 million HIV infusion fraud scheme and conviction of 13 DME company owners involved in a $6.4 million plan where false claims were submitted for DME supplies, including aerosol medications and oxygen concentrators.

Breuer told the panel that the resources available for fraud detection and control in the healthcare industry "are not only inadequate but at the wrong scale. We don't know how much we are losing in these programs."

On questioning from Sen. Jeff Sessions (R-AL), Breuer told the panel that the Justice Department was not looking for cases, for example, where hospitals or physicians may have miscoded Medicare claims.

"We're not targeting those who make mistakes," Breuer said. "We're looking for extraordinary aberrations in the numbers."

Janice Simmons contributed to this report.


Ben Amirault is an Editorial Assistant for the revenue cycle division of HCPro, Inc. He manages the Compliance Monitor e-newsletter and has developed a number of online learning modules. He can be reached at bamirault@hcpro.com.

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