- The Washington Times - Tuesday, December 1, 2009

Starting in the spring of 2007, federal, state and local law enforcement officials came together in South Florida to hunt down and charge people with defrauding the country’s multibillion-dollar Medicare system.

Known as the Medicare Fraud Strike Force and now expanded across the country, the group has since indicted more than 300 health care providers nationwide and has broken up operations that accounted for more than $700 million in fraudulent Medicare claims.

Former U.S. Attorney R. Alexander Acosta, who put a priority on health care fraud cases when he was the government’s chief prosecutor in Miami, said the decision in Washington to make such coordinated efforts permanent is starting to have an impact, but that more needs to be done to make a real dent in the kickback and false-billing schemes that plague the national health care program.

“The fight against health care fraud had already begun at the local level, but the strike forces brought additional manpower, expertise and necessary resources,” said Mr. Acosta, now dean of the Florida International University College of Law in Miami.

“They put a spotlight on a national problem, allowed us to continue our work and more than doubled the resources available to us,” he said. “It has become a very successful partnership for a too-often-ignored problem.”

Assistant Attorney General Lanny A. Breuer, who heads the Justice Department’s criminal division, told the Senate in May that federal and state spending on Medicare and Medicaid totaled $800 billion a year and that “according to various estimates, somewhere between 3 and 10 percent of this spending is lost to waste, fraud and abuse.”

Mr. Breuer told The Washington Times that because criminals are “devising more sophisticated ways of stealing billions of dollars from federally administered health care programs, and they are stealing it faster now than ever before,” the Justice Department is committed to shutting them down.

“We must stop the bleeding, and we are committed to do so,” he said.

Medicare is a government-paid insurance program begun in 1965 that provides health care to about 40 million people 65 and older and 7 million younger people with permanent disabilities. The program accounted for about 13 percent of the federal budget and 19 percent of the total health care expenditures in 2008.

Health and Human Services Secretary Kathleen Sebelius said the strike force has a “proven record of success,” using a data-driven approach to identify unexplainable billing patterns and investigate providers for fraudulent activity.

Building on early strike-force successes under President George W. Bush in South Florida in 2007 and in Los Angeles in 2008, the Obama administration created new strike-force operations in Detroit and Houston in March this year.

Program integrity

Fraud-prevention efforts also have been strengthened in President Obamas proposed fiscal 2010 budget, which invests $311 million - a 50 percent increase over fiscal 2009 - to bolster “program integrity” activities within the Medicare and Medicaid programs.

The anti-fraud efforts in the presidents budget could save $2.7 billion over five years by improving oversight and stopping fraud in the Medicare and Medicaid programs, Justice Department and HHS officials have estimated. The officials said that since the program’s inception, the strike forces have filed more than 130 cases, charged more than 300 people, accepted 15 guilty pleas and won 21 convictions in 15 jury trials.

And the number of cases has been multiplying in recent months.

In July, a federal grand jury in Houston indicted 32 people on charges of submitting more than $16 million in phony Medicare claims. In some cases, the indictment said, beneficiaries were deceased at the time the services were billed.

That same month, a federal grand jury in Los Angeles convicted the operators of a durable medical equipment company that falsely billed Medicare for $949,859 and were paid $597,750 for medically unnecessary power wheelchairs and accessories. The elderly beneficiaries said they were promised vitamins, diabetic shoes and other items they never received in exchange for their Medicare numbers. None of those who received a wheelchair needed one or used it.

In June, a federal grand jury in Detroit indicted 53 people in a $50 million scheme to submit claims to Medicare for treatments that were medically unnecessary and often were never provided. In many cases, the indictments said, the beneficiaries accepted cash kickbacks in return for allowing health care providers to submit forms saying they had received the treatments.

Also in June, a Miami doctor was sentenced to 97 months in prison in a $20 million Medicare scheme involving HIV infusion services. The doctor admitted being the co-owner of five Miami clinics that purported to specialize in the treatment of HIV patients, but he routinely billed Medicare for services that were not needed and often were never delivered.

The government also has targeted major corporations in the effort to bring some control to Medicare and Medicaid fraud.

In September, U.S. pharmaceutical giant Pfizer Inc. and a subsidiary, Pharmacia & Upjohn Co. Inc., agreed to pay a $2.3 billion settlement to resolve criminal and civil liability allegations that it fraudulently sold drugs, many of which were based on Medicare and Medicaid claims.

The settlement, which was the result of an inquiry begun during the Bush administration, was described by Justice Department and HHS officials as the largest-ever health care fraud settlement.

Clear message

Kevin Perkins, assistant director of the FBI’s Criminal Investigative Division, said in announcing the settlement that it “sends a clear message the FBI and our partners will not stand by and let any manufacturer peddle their prescriptions or products for uses beyond their intended - and federal government-approved - purpose.”

“The FBI will not be deterred from continuing to ensure that pharmaceutical companies conduct business in a lawful manner,” he said.

The task force is getting extra help, bolstered by the creation this year of the Health Care Fraud Prevention & Enforcement Action Team, a federal, state and local effort to prevent fraud and enforce anti-fraud laws nationwide through data analysis techniques and an increased focus on community policing.

The creation of the team means that fighting health care fraud has become a Cabinet-level priority task for the Departments of Justice and Health and Human Services. The task force is co-chaired by Deputy Attorney General David Ogden at Justice and Deputy Secretary Bill Corr at HHS and is composed of top-level law enforcement agents, prosecutors and staff from both departments.

Mr. Breuer said the government’s new coordinated effort against health care fraud has allowed the strike force to identify criminal-claim trends and track weaknesses to stop false claims before they occur. But, he said, officials also have learned that “we cannot prosecute our way out of this problem.”

“Instead, we must prevent criminals from accessing Medicare, Medicaid and other health care programs in the first place,” he said, and that effort has just begun.

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