Justice Dept summary of health care fraud fighting

https://www.justice.gov/opa/speech/assistant-attorney-general-leslie-r-caldwell-speaks-health-care-compliance-association-s

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Some of you have been in this field long enough to recall the days when the Criminal Division and its law enforcement partners were essentially reactive in health care fraud cases. Prosecutors relied primarily on referrals that came through the Centers for Medicare and Medicaid Services—or CMS—for investigation and prosecution. CMS maintained control of the health care billing data, and prosecutors relied upon CMS to both provide and analyze it. At the time, the Criminal Division was focused primarily on “storefront cases,” or cases in which businesses billed Medicare, but were not actually providing services or equipment. We have come a long way since those days.

The Criminal Division began its intensive health care fraud enforcement efforts in 2007 with the creation of the Medicare Fraud Strike Force, which began in Miami, in partnership with the FBI and the Department of Health and Human Services’ Office of the Inspector General (HHS-OIG).

In its infancy, the strike force targeted Medicare billing categories known to be rife with fraud, such as durable medical equipment. We tackled power wheelchairs and orthotics and hospital beds. Within one year, the Criminal Division’s enforcement efforts, along with administrative actions taken by HHS, contributed to a $1 billion drop in durable medical equipment billings in the Miami area.

Since those early successes, we have expanded the strike force to eight additional cities that are hot spots for Medicare fraud: Tampa, Baton Rouge, Dallas, Houston, Brooklyn, Detroit, Chicago and Los Angeles. The strike force focuses exclusively on one thing—prosecuting Medicare fraud—and has developed successful partnerships with law enforcement and a proven model for investigations and prosecutions. Since its inception in 2007, the Medicare Fraud Strike Force has charged more than 2,300 defendants who had collectively billed the Medicare program for more than $7 billion.

In the last fiscal year alone, the strike force charged 391 defendants who had collectively billed the Medicare program approximately $1.4 billion. During the last fiscal year, the strike force had a conviction rate of 92 percent—a spectacular rate of success considering the volume and the complexity of the prosecutions—and secured prison sentences averaging 56 months.

In June of last year, strike force prosecutors in 17 districts executed a nationwide operation that resulted in charges against 243 individuals, including 46 doctors, nurses and other licensed medical professionals, for their participation in Medicare fraud schemes involving approximately $712 million in false billings. This coordinated takedown was the largest in strike force history, both in terms of the number of defendants and loss amount, and it will by no means be the last.
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It’s not only the high number of prosecutions that demonstrate the strike force’s success, but also the level and sophistication of the individuals prosecuted. In the last fiscal year, the strike force has charged 83 licensed medical professionals. These are individuals who have breached the public trust and their professional duties of care, selling their medical licenses for the lure of easy money, and oftentimes preying on vulnerable Medicare beneficiaries.
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So, where is the Criminal Division headed now?

The Medicare Fraud Strike Force will continue to use billing data to create and corroborate investigative leads. We will invest in resources to maximize the usefulness of this information, expending every effort to remain ahead of emerging fraud trends, including Medicare Part D, drug diversion, laboratory services, hospital-based services and hospice care. These are the latest frontiers in Medicare fraud. We are working hard to identify those engaged in these new schemes and to bring them to justice.

Last month, the department launched 10 regional Elder Justice Task Forces, which will bring together federal, state, and local prosecutors, law enforcement and agencies that provide services to the elderly to coordinate and enhance efforts to pursue nursing homes that provide grossly substandard care to their residents, many of whom are Medicare and Medicaid beneficiaries. These can be challenging, but necessary, federal criminal health care fraud cases to bring. We expect to continue to build more momentum in this area.
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addressing large-scale corporate health care fraud is a priority for the department. To that end, in late 2015, the Fraud Section formed a separate Corporate Health Care Fraud Unit. We now have over a dozen active corporate investigations, and we are steering additional prosecutorial resources to this area. The unit is staffed by experienced health care fraud prosecutors, who carefully review virtually every False Claims Act lawsuit filed by qui tam relators across the United States. In many instances, qui tams are valuable sources of corporate fraud referrals.
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