Overview of Federal and State Healthcare Fraud and Abuse Initiatives

Transcription

1 Overview f Federal and State Healthcare Fraud and Abuse Initiatives PREPARED BY MATTHIAS KASEORG AND NATHAN KOTTKAMP Given the size and scpe f healthcare expenditures in the United States, the healthcare industry has been a majr target f fraud and abuse. In respnse, bth Federal and State gvernments have develped myriad initiatives t target such activities. The gvernment has made great strides in the past decade in establishing several key prgrams and partnerships that fcus n crdinatin and cperatin between varius agencies t cmbat healthcare fraud and abuse. The gvernment has als utilized, t great success, advances in infrmatin technlgy t cllect and analyze large amunts f data t predict, uncver, and prevent healthcare fraud and abuse. Belw is an verview f several key initiatives. FEDERAL HEALTH CARE FRAUD AND ABUSE CONTROL (HCFAC) PROGRAMS BUDGET Mandatry Resurces Fiscal Year 2013 Office f Inspectr General $187,097,926 Health and Human Services Wedge $34,819,122 Medicare Integrity Prgram $851,509,634 MIP/Medicare (nn-add) $797,581,005 Medi-Medi (nn-add) $53,928,629 Department f Justice Wedge $58,164,042 Federal Bureau f Investigatin $128,149,615 Subttal, Mandatry HCFAC $1,259,740,339 Discretinary Resurces Office f Inspectr General $28,121,691 CMS Prgram Integrity $237,343,109 Medicare Prgram Integrity (Nn-Add) $207,984,175 Medicaid Prgram Integrity (Nn-Add) $29,358,934 Department f Justice $28,121,691 Subttal, Discretinary HCFAC $293,586,491 Grand Ttal, HCFAC $1,553,326,830 The Inspectr General fr the U.S. Department f Health and Human Services recently reprted that fr every dllar the Departments f Justice (DOJ) and Health and Human Services (HHS) have spent fighting health care fraud, they have returned an average f nearly eight dllars t the U.S. Treasury, the Medicare Trust Fund, and thers. Sequestratin hit the DOJ and HHS hard. A ttal f $30.6 millin was sequestered frm the HCFAC prgram fr fiscal year THE HEALTH CARE FRAUD PREVENTION AND ENFORCEMENT ACTION TEAM (HEAT) The Health Care Fraud Preventin & Enfrcement Actin Team (HEAT) was established in May 2009 as a cabinet-level cmmitment t bth prevent health care fraud and enfrce current anti-fraud laws prevent and prsecute health care fraud arund the cuntry. HEAT is jintly led by the Deputy Attrney General and HHS Deputy Secretary. HEAT is cmprised f tp level law enfrcement agents, prsecutrs, attrneys, auditrs, evaluatrs, and ther staff frm DOJ and HHS and their perating divisins. 900 LAWYERS 20 OFFICES

2 The Medicare Fraud Strike Frce prgram, explained belw, is a key cmpnent f HEAT. THE HEALTHCARE FRAUD PREVENTION PARTNERSHIP (HFPP) The Healthcare Fraud Preventin Partnership (HFPP) is the grundbreaking public/private partnership between the gvernment and private sectr insurance payers. The purpse f the partnership is t exchange data and infrmatin between the partners t help imprve capabilities t fight fraud, waste and abuse in the health care industry. Current partners include federal (HHS-OIG, DOJ, FBI, CMS), states, private plans, and assciatins. HFFO s first infrmatin sharing study included exchanging cdes and cde cmbinatins frequently assciated with fraud, waste, r abuse, as well as fraud schemes and descriptins. THE DOJ-HHS MEDICARE STRIKE FORCE The jint DOJ-HHS Medicare Fraud Strike Frce is a multi-agency team f federal, state, and lcal investigatrs designed t fight Medicare fraud. The Strike Frce uses Medicare data analysis techniques and an increased fcus n cmmunity plicing t cmbat fraud. The Strike Frce teams use advanced data analysis techniques t identify high-billing levels in health care fraud ht spts s that interagency teams can target emerging r migrating schemes alng with chrnic fraud by criminals masquerading as health care prviders r suppliers. The Center Fr Medicare and Medicaid Services (CMS) has designated prgram integrity field ffices lcated in r near Miami, Ls Angeles, and Brklyn with CMS Strike Frce Liaisns, wh: Crdinate with law enfrcement Facilitate data analysis Expedite suspensin requests Wrk with CMS and Zne Prgram Integrity Cntractrs t cnduct data analysis t practively identify targets and t crdinate effrts amng varius cntractrs and agencies t identify lcal issues and vulnerabilities with natinal r reginal impact The Strike Frce is currently perating in nine cities: Batn Ruge, Luisiana Brklyn, New Yrk Chicag, Illinis Dallas, Texas Detrit, Michigan Hustn, Texas Ls Angeles, Califrnia Miami, Flrida Tampa, Flrida HHS reprts the fllwing prgress since the Strike Frce started seven years ag: Strike Frce prsecutrs filed mre than 788 cases charging mre than 1,727 defendants wh cllectively billed the Medicare prgram mre than $5.5 billin 1,137 defendants pleaded guilty and 148 thers were cnvicted in jury trials

3 1,087 defendants were sentenced t imprisnment fr an average term f apprximately 47 mnths HHS reprts the fllwing Strike Frce accmplishments in 2013: 137 indictments, infrmatins [frmal criminal charge pleading], and cmplaints invlving charges filed against 345 defendants wh allegedly cllectively billed the Medicare prgram mre than $1.1 billin 234 guilty pleas negtiated and 34 jury trials litigated, with guilty verdicts against 48 defendants Imprisnment fr 229 defendants sentenced during the fiscal year, averaging mre than 52 mnths f incarceratin Example f Strike Frce activity: In May 2013, a natinwide takedwn by Medicare Fraud Strike Frce peratins in eight cities resulted in charges against 89 individuals, including dctrs, nurses and ther licensed medical prfessinals, fr their alleged participatin in Medicare fraud schemes invlving apprximately $223 millin in false billings. The defendants charged were accused f varius health care fraud-related crimes, including cnspiracy t cmmit health care fraud, vilatins f the anti-kickback statutes and mney laundering. The charges were based n a variety f alleged fraud schemes invlving varius medical treatments and services, primarily hme health care, but als mental health services, psychtherapy, physical and ccupatinal therapy, durable medical equipment (DME) and ambulance services. This crdinated takedwn was the sixth natinal Medicare fraud takedwn in Strike Frce histry. HHS AUDITS HHS als uses targeted audits t uncver misuse f Medicare and Medicaid dllars. In 2013 HHS targeted audits at the fllwing: Preventing and Detecting Medicaid Fraud Medicaid Payments t Excluded Prviders Medicaid Data fr Prgram Integrity Medicaid Disprprtinate Share Hspital Payments Medicaid Inpatient Psychiatric Services Medicaid Payments fr Persnal Care Services Medicaid Hme Health Services Medicaid Family-Based Treatment Rehabilitatin Services Medicaid Family Planning Services Medicaid Schl-Based Services Medicaid Overpayments Detecting Fraud in Medicare Theft f Medicare Identities Part C and Part D Prgram Integrity Activities Payments fr Individuals Ineligible fr Medicare

4 Medicare Payment fr Cancelled Surgeries Medicare Medical Equipment and Supplies Medicare Payments fr Drugs Medicare Skilled Nursing Facilities Medicare Incentive Payments fr Electrnic Health Recrds Medicare Part C Capitatin Payments Medicare Part D Drugs HCFAC PROGRAM OVERSIGHT HHS s Office f the Inspectr General (OIG) cntinues t use data mining, predictive analytics, trend evaluatin, and mdeling appraches t better analyze and target the versight f HHS prgrams. Analysis teams use near-time data t examine Medicare claims fr knwn fraud patterns, identify suspected fraud trends, and t calculate ratis f allwed services as cmpared with natinal averages, as well as ther assessments. OIG S PROVIDER SELF-DISCLOSURE PROTOCOL (SDP) In 1998, OIG published the Prvider Self-Disclsure Prtcl t establish a prcess fr health care prviders t vluntarily identify, disclse, and reslve instances f ptential fraud invlving the Federal health care prgrams. Vluntary disclsure des nt guarantee any srt f settlement. Hwever, OIG wuld prefer t reslve an issue thrugh settlement rather than trial, and health care prviders can mitigate the risk f civil mnetary penalties, criminal prsecutin, and prgram exclusin by vluntarily disclsing ptential instances f fraud thrugh the SDP. Since 1998, OIG has reslved ver 800 disclsures, resulting in recveries f mre than $280 millin t the Federal health care prgrams. Over 200 matters have been disclsed under the new Stark self-disclsure prtcl. Self-disclsure f ptential fraud can limit civil penalties. OIG reprts that its general practice in Civil Mnetary Penalty settlements f SDP matters is t require a minimum multiplier f 1.5 times the single damages, which is far lwer than the ptential criminal and civil penalties available if the case were t be prsecuted. Self-disclsure f ptential fraud can als limit prgram exclusin. Since 2008, OIG has reslved 235 SDP cases thrugh settlements. In all but ne f these cases, OIG released the disclsing parties frm permissive exclusin withut requiring any integrity measures. VIRGINIA S MEDICAID FRAUD CONTROL UNIT (MFCU) The Virginia Medicaid Fraud Cntrl Unit (MFCU) f the Office f the Attrney General was certified Octber 1, 1982, by the United States Department f Health and Human Services. The Unit is ne f 50 units thrughut the United States with the same missin. In deciding t establish a MFCU in Virginia, the General Assembly stated: The General Assembly finds and declares it t be in the public interest and fr the prtectin f the health and welfare f the residents f the Cmmnwealth that a prper regulatry and inspectin prgram be instituted in cnnectin with the prviding f medical, dental and ther health services t recipients f medical assistance. In rder t effectively accmplish such purpse and t assure that the recipient receives such services as are paid fr by the Cmmnwealth, the acceptance by the recipient f such services and the acceptance by practitiners f reimbursement fr perfrming such services shall authrize the Attrney General r his authrized representative t inspect and audit all recrds in cnnectin with the prviding f such services. Virginia Cde

5 **** The MFCU emplys a prfessinal staff f criminal investigatrs, auditrs, attrneys and supprt staff wh wrk tgether t develp investigatins and prsecute cases. The Virginia MFCU wrks regularly with federal, state and lcal law enfrcement agencies t cmbat fraud, prtect ur mst vulnerable citizens and t save taxpayer dllars. Since 1982, the MFCU has recvered mre than $800 millin in criminal and civil recveries including affirmative civil enfrcement cases (rdered and cllected reimbursements, fines and restitutins). In 2008, the Virginia MFCU was named the number ne MFCU in the cuntry by the United States Department f Health and Human Services, Office f Inspectr General. The MFCU is prud t serve amng the natin s leaders in cmbating fraud in the Medicaid prgram. SOURCES: