Medicare/Medicaid entities fight healthcare fraud and abuse. The Medicare Fraud Strike Force and Medicaid Control Units have worked to stem healthcare fraud and abuse.
The Medicare Fraud Strike Force, established in March 2007, analyzes data and investigates intelligence to rapidly detect fraud and initiate prosecutions. A collaborative effort among the Office of Inspector General (OIG), U.S. Department of Justice (DOJ), Offices of the U.S. Attorneys, Federal Bureau of Investigation (FBI), local law enforcement, and others, the Strike Force operates in nine locations: Miami, Florida; Los Angeles, California; Detroit, Michigan; southern Texas; Brooklyn, New York; southern Louisiana; Tampa, Florida; Chicago, Illinois; and Dallas, Texas. Its operations are part of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint initiative announced in May 2009 between the DOJ and the U.S. Department of Health and Human Services (HHS) to focus efforts to prevent and deter fraud and enforce current antifraud laws nationwide. HEAT is comprised of law enforcement agents, prosecutors, attorneys, auditors, evaluators, and other DOJ and HHS staff.
According to Assistant Attorney General Leslie R. Caldwell, the Strike Force’s strategic approach has been remarkably successful at staying ahead of healthcare fraud trends. Since its inception, the Strike Force has charged over 2,900 defendants who collectively falsely billed Medicare for over $8.9 billion.
Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud, as well as patient abuse and neglect in healthcare facilities and board and care facilities. The MFCUs are single, identifiable entities that are separate and distinct from state Medicaid agencies. Typically as part of state attorney general offices, the MFCUs employ teams of investigators, attorneys, and auditors. The OIG exercises oversight for the MFCUs and annually recertifies each MFCU, assesses each MFCU’s performance and compliance with federal requirements, and administers a federal grant award to fund a portion of each MFCU’s operational costs.
Legislation addresses healthcare fraud and abuse. Legislation addressing healthcare fraud and abuse includes the Affordable Care Act, the False Claims Act, and the Anti-Kickback Statute.
The Affordable Care Act (ACA) provides tools and resources to fight federal healthcare fraud. The ACA provides $350 million to HHS’s prevention and enforcement efforts, enabling HHS to hire additional prosecutors and expand the Strike Force. This grants the Centers for Medicare and Medicaid Services (CMS) greater authority to screen out questionable providers and suppliers prior to their enrollment in Medicare and increases data sharing across government. The ACA clarifies that the sum amount billed to Medicare determines the loss due to the healthcare fraud; the ACA increases prison time for the billed amounts, thus acting as a deterrent to committing fraud.
A defendant is guilty of committing a crime under the False Claims Act if the defendant knowingly and willfully submitted a false claim to the federal government for reimbursement. Intent is the heart of this act. A conviction under the False Claims Act makes the defendant automatically liable for civil false claims penalties. If the defendant meets the standard of proof, the defendant will most likely be barred from doing business with the federal government.
A defendant is guilty of committing a felony under the Anti-Kickback Statute if the defendant knowingly and willfully exchanges, or offers to exchange, anything of value (including any kickback, bribe, or rebate) in an effort to induce the referral of federal healthcare program business. Conviction under the Anti-Kickback Statute results in mandatory exclusion from participation in federal healthcare programs.