National Medicare fraud takedown results in charges against 243 individuals for approximately $712 million in false billing

This is all fine and appropriate.  However, the underlying problem is that the way Medicare operates, unlike private health insurance, it does virtually no prospective or concurrent review of claims for medical necessity. As a result tracking down fraud takes years. In some of the examples in this release the fraud began in 2006 and now nine years later has been uncovered.  That, sadly, is the consequence of a massive bureaucracy with no motive to be diligent and a lot of political motivation to pay claims without hassling beneficiaries.

National Medicare fraud takedown results in charges against 243 individuals for approximately $712 million in false billing

Most defendants charged and largest alleged loss amount in Strike Force history

WASHINGTON – Department of Health and Human Services (HHS) Secretary Sylvia M. Burwell and Attorney General Loretta E. Lynch announced today a nationwide sweep led by the Medicare Fraud Strike Force in 17 districts, resulting in charges against 243 individuals, including 46 doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $712 million in false billings.  In addition, the Centers for Medicare & Medicaid Services (CMS) also suspended a number of providers using its suspension authority as provided in the Affordable Care Act.  This coordinated takedown is the largest in Strike Force history, both in terms of the number of defendants charged and loss amount.

Secretary Burwell and Attorney General Lynch were joined in the announcement by FBI Director James B. Comey, Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division, Inspector General Daniel R. Levinson of the HHS Office of Inspector General (HHS-OIG) and Deputy Administrator and Director of CMS Center for Program Integrity Dr. Shantanu Agrawal.

The defendants are charged with various health care fraud-related crimes, including conspiracy to commit health care fraud, violations of the anti-kickback statutes, money laundering and aggravated identity theft.  The charges are based on a variety of alleged fraud schemes involving various medical treatments and services, including home health care, psychotherapy, physical and occupational therapy, durable medical equipment (DME) and pharmacy fraud.  More than 44 of the defendants arrested are charged with fraud related to the Medicare prescription drug benefit program known as Part D, which is the fastest-growing component of the Medicare program overall.

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