Federal Anti-Fraud Efforts Call for More Scrutiny of Providers

Obama administration officials, reporting Thursday that a record $2.5 billion was deposited into the Medicare Trust Fund in fiscal 2009 from anti-fraud efforts, said they will be increasing their efforts under healthcare reform. That means tighter oversight and increased enforcement to detect and stop Medicare and Medicaid fraud.

"Under this new [reform] law, we're going to attack fraud at every stage of the process," said Health and Human Services Secretary Kathleen Sebelius, at a Washington news conference. One of the top areas they are strengthening is screening and background checks for healthcare providers who want to participate in the Medicare and Medicaid programs.

"The days when you could just hang a shingle and start submitting claims are over," she said. There will be "much tighter screening for providers to actually become enrolled in the first place [with] verification that wasn't in place before so people can't just become providers and start billing under false pretenses."

There will be "more opportunity to do face-to-face checks of who is actually setting up shop," she added. This will be accompanied by "more opportunity to look at data systems and find aberrant billing patterns—tracking things much more quickly."

To get providers, as well as Medicare and Medicaid suppliers up to speed with requirements, HHS will be making "resources for us to conduct compliance training programs" in the upcoming year, said HHS Inspector General Daniel Levinson.

"The training will focus on methods to identify fraud risk areas and compliance best practices so providers can strengthen their own compliance efforts and more effectively identify and avoid illegal schemes that may be targeting their communities," Levinson said.

In addition, efforts are being made to "make it easier for law enforcement to see healthcare claims data from different government agencies in one place," Sebelius said. Under the previous system, "police officers in one town weren't talking to the officers in the next town over . . . Giving law enforcement agents access to the big picture will help them identify suspicious patterns in claims data that can indicate fraud."

Also, "to get more boots on the ground to fight fraud in communities across the country," an additional $600 million is going to be used over the next 10 years by HHS and the Justice Department to improve anti fraud programs, Sebelius added.

"For every dollar that we spend preventing healthcare fraud, we're able to return $4 to the U.S. Treasury," said U.S. Attorney General Eric Holder, at the joint press conference. "Over the years, we’ve seen that as long as healthcare fraud pays and goes unpunished, our healthcare system will remain under siege."

The $2.5 billion deposited to the Medicare Trust Fund was $569 million more, or a 29% increase, than the total of $1.9 billion collected the year before, Holder said. In addition to that money, another $441 million in federal Medicaid money also was returned to the Treasury Department, a 28% increase from the previous year.

Also in fiscal 2009, the Justice Department's Criminal Division and the U.S. Attorneys' Offices opened 1,014 new criminal healthcare fraud investigations and had 1,621 healthcare fraud criminal investigations pending, Holder said.

"We reached an all time high in the number of healthcare fraud defendants charged, with more than 800 indictments in nearly 500 cases and close to 600 convictions," Holder said. The Justice Department’s Civil Division opened nearly 900 new civil healthcare fraud investigations and had more than 1,100 pending cases.

Holder also announced that the Medicare Fraud Strike Forces prosecutors, working as part of the joint HHS-Justice Department Health Care Fraud Prevention & Enforcement Action Team (HEAT) announced last May, have sought approximately $500 million in court ordered restitution to the Medicare program in nearly 300 healthcare fraud cases involving more than 560 defendants. The strike forces now cover seven regions of the country—from South Florida to Detroit to Houston.

Sebelius also commented on criminal schemes that have popped up with the passage of healthcare reform legislation. "In states like Delaware and Wyoming, we've heard that scam artists are calling up seniors and telling them they need to share their Medicare ID numbers in order to get the law's new benefits," she said.

In other states, seniors have been asked for personal information in order to get their "new Medicare ID cards," which don't exist.

"These are old crimes with a new spin," she said. "My message to them today is this: there has never been a worse time to try to steal Americans' healthcare dollars."