September 13, 2016 Articles

Medicare Fraud: A Historic Takedown

The Affordable Care Act provides tools and resources to fight federal healthcare fraud.

By Ariella Cohen – September 13, 2016

The largest healthcare fraud takedown in history occurred on June 22, 2016, following an operation led by the Medicare Fraud Strike Force. The unprecedented nationwide sweep in 36 federal districts led to the charging of 301 individuals, including physicians, nurses, other licensed professionals, and healthcare company owners for their involvement in $900 million of fraudulent billing.

Basics of Healthcare Fraud and Abuse 
In cases of healthcare fraud and abuse, defendants use or seek to use public finances for private benefit. Fraud occurs when a defendant submits, or causes someone to submit, false or misleading information for the purpose of reimbursement. Abuse occurs when provider practices are inconsistent with sound fiscal, business, or medical practices, resulting in unnecessary cost or in reimbursement for services that are medically unnecessary or fail to meet the standard of care. These criminals promise treatments but fail to provide any. They abuse trust, such as between doctor and patient, pharmacist and doctor, or taxpayer and government.

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