Federal Efforts to Crack Down on Health Care Fraud

Federal Efforts to Crack Down on Health Care Fraud

Health care fraud is a big problem in the United States. It happens when people lie to get more money from health insurance programs. The government wants to stop health care fraud. They are making new rules and laws to crack down on it.

What is Health Care Fraud?

Health care fraud happens in a few main ways:

• Doctors bill for services they didn’t really do
• Clinics bill for more expensive services than they actually did
• Companies sell medical equipment to patients who don’t need it
• People lie about their health to get unneeded prescriptions

All of these things are illegal. They cost taxpayers and insurance companies billions of dollars every year. The government wants to stop fraudsters from cheating health care programs.

Federal Agencies Fighting Fraud

Many government agencies work to stop health care fraud. Here are some of the main ones:

• Department of Justice (DOJ)
• Department of Health and Human Services (HHS)
• Federal Bureau of Investigation (FBI)
• Centers for Medicare and Medicaid Services (CMS)

These agencies investigate fraud cases. They also make rules to prevent fraud from happening. When they catch fraudsters, they take them to court or fine them.

Department of Justice

The DOJ announced charges against 78 people in June 2022. They were accused of $2.5 billion in health care fraud schemes. The DOJ has a Health Care Fraud Strike Force that investigates major fraud cases. They have brought charges against hundreds of people.

Department of Health and Human Services

HHS works with the DOJ on investigating fraud. The HHS Office of Inspector General (OIG) looks into fraud in Medicare, Medicaid, and other HHS programs. In June 2023, the OIG announced a nationwide COVID-19 fraud enforcement action. They charged people with falsely billing for COVID-19 services and stealing from pandemic relief funds.

FBI and CMS

The FBI also investigates major health care fraud schemes. They work with DOJ prosecutors to bring criminal charges. CMS manages Medicare and Medicaid programs. They make rules to close loopholes and prevent fraudsters from cheating the system.

New Efforts to Fight Fraud

Health care fraud costs taxpayers billions of dollars each year. To crack down, federal agencies are using new tools and efforts.

More Coordination Between Agencies

In the past, federal agencies did not coordinate as much to fight fraud. Now the DOJ, HHS, FBI, and CMS are working together better. They share information and resources to build stronger cases against fraudsters.

New Strike Forces and Task Forces

The DOJ has set up special strike forces in fraud hot spots around the country. These teams only focus on investigating health care fraud. The HHS OIG also has regional task forces to fight fraud.

Advanced Data Analysis

Federal agencies are using computers to analyze Medicare and Medicaid claims data. This can spot unusual patterns that might show fraud. Advanced analytics help investigators find the biggest fraud schemes.

Increased Use of Technology

Agencies are using new technology to detect and prevent fraud. For example, CMS uses data mining to screen Medicare claims. This flags suspicious claims before payments go out. Technology helps investigators spot fraud faster.

Stiffer Penalties for Fraudsters

New laws increased the fines and jail time for health care fraud. This makes punishments more severe. The DOJ hopes bigger penalties will deter fraudsters.

Major Health Care Fraud Schemes

Federal agencies have cracked down on many big fraud schemes in recent years. Here are some examples of major cases:

Pill Mill Clinics

“Pill mills” are clinics that prescribe lots of opioids illegally. Investigators have busted doctors running pill mills that defrauded Medicare of millions. The DOJ charged one scheme in Ohio with $100 million in false billings.

DNA Cancer Testing

Some labs billed Medicare for expensive DNA cancer tests that were not medically necessary. In 2020, the DOJ charged dozens of people in a $2 billion genetic testing fraud scheme.

Home Health Care

Fraudsters bill Medicare for home health services that patients don’t get. A Texas company was convicted of a $150 million home health fraud scheme. Employees falsified documents to cover up the fraud.

Telemedicine

Scammers use telemedicine to bill for unnecessary medical equipment. A telemedicine scheme cost Medicare $4.5 billion by prescribing unneeded back, shoulder, wrist and knee braces.

Nursing Homes

Some nursing homes bill Medicare for services never performed or inflate the level of patient care needed. A nursing home chain in Georgia was fined $43 million for fraudulent billing practices.

Pandemic Fraud

The COVID-19 pandemic led to new types of health care fraud. Scammers have stolen billions from programs meant to help fight the pandemic.

Provider Relief Funds

The CARES Act provided relief funds to help health providers during the pandemic. The DOJ charged people who lied to get these funds and used them for personal expenses.

Fake COVID-19 Tests

Some labs billed Medicare for unnecessary COVID-19 tests. Others charged for tests that were never performed. Fake COVID test schemes have cost taxpayers over $140 million.

Fake Vaccine Cards

The FBI busted groups selling fake COVID-19 vaccination cards. People used these cards to lie about getting vaccinated against COVID-19.

Impact of Fraud Crackdown

The federal crackdown on fraud has had a big impact. Billions of dollars in fraudulent payments have been stopped. However, health care fraud remains a major problem. More work is needed to prevent fraud and abuse.

Billions in Savings

DOJ fraud investigations from 2018 to 2022 returned over $9.5 billion to the federal government. This includes fines paid by fraudsters and fraudulent claims stopped.

Hundreds Convicted

Hundreds of doctors, nurses, clinic owners and others have been convicted of health care fraud. Many received lengthy prison sentences for stealing from Medicare and Medicaid.

Changed Industry Practices

The crackdown has led health providers to improve practices. Many have increased internal audits and compliance programs to avoid fraud issues. However, there are still many bad actors engaged in fraud.

Fraud Still Widespread

Despite the crackdown, health care fraud remains widespread. Criminals find new ways to cheat Medicare and Medicaid. Ongoing enforcement efforts are needed to combat constantly evolving fraud schemes.

Future of Fraud Enforcement

Federal agencies plan to expand efforts to eliminate health care fraud. New initiatives aim to improve prevention and detection of fraud schemes.

More Provider Screening

CMS will increase screening of providers who bill Medicare and Medicaid. This can help stop fraudsters from entering these programs in the first place.

Advanced Analytics

Federal investigators will expand the use of data analytics to proactively identify likely fraud before payments occur. This will move efforts earlier in the fraud cycle.