The Department of Justice (DOJ) recently issued its annual Health Care Fraud Takedown results, announcing a record-breaking 324 defendants, including 96 doctors and licensed professionals, as well as more than $14.6 billion in intended loss. While the large figures grab attention, an analysis of the DOJ’s statements offers important insight for American health care professionals and companies: Despite various executive orders and policy changes with the new administration, the DOJ and other government agencies continue to focus significant resources on investigating and prosecuting domestic health care fraud.
International Reach
The report shows DOJ’s efforts against Transnational Criminal Organizations (TROs). In total, 29 defendants were charged for schemes that resulted in the submission of over $12 billion in fraudulent claims. In one scheme, Operation Gold Rush, foreign actors bought several medical supply companies in the United States and used stolen identities of Americans to submit more than $10.6 billion in fraudulent health care claims to Medicare. The focus on TROs has been a common thread of this administration’s enforcement priorities, as demonstrated by its recent memorandum to the DOJ’s criminal division on how to use the Foreign Corrupt Practices Act.
Preventing Opioid Abuse
DOJ charged 74 defendants for distribution of more than 15 million pills of prescription opioids and other controlled substances. The announcement signals the continued commitment of DOJ’s Health Care Fraud Unit to finding bad actors who continue to perpetuate the devastating epidemic of prescription opioid abuse. This extends to the Drug Enforcement Agency that, according to the DOJ announcement, has “charged 93 administrative cases seeking the revocation of pharmacies, medical practitioners and companies’ authority to handle and/or prescribe controlled substances” in the last six months.
Message for Domestic Health Care Providers
The press release highlights the continuing, and growing, use of artificial intelligence, data analytics and cloud computing to discover potential health care fraud schemes. DOJ’s data analysts will be partnering with other federal agencies to “increase efficiency, detection, and rapid prosecution.” The goal is to “reduc[e] duplicative data teams, increas[e] operational efficiency through a whole-government approach and leverag[e] cloud computing, artificial intelligence, and other agency resources.” Cross-agency enforcement actions will become the new norm, and cases will be brought based on data collected and analyzed through increasingly shared technologies.
The message to American health care professionals and companies is clear: remain vigilant of the threat of healthcare fraud. Matthew R. Galeotti, head of the Justice Department’s Criminal Division, said the it remains “intensely committed to rooting out health care fraud schemes and prosecuting the criminals who perpetrate them because these schemes: (1) often result in physical patient harm through medically unnecessary treatments or failure to provide the correct treatments; (2) contribute to our nationwide opioid epidemic and exacerbate controlled substance addiction; and (3) do all of that while stealing money hardworking Americans contribute to pay for the care of their elders and other vulnerable citizens.”
The schemes that Galeotti calls out are neither new nor distant to law enforcement. As we have previously noted, DOJ has a longstanding commitment to rooting out billing for medically unnecessary treatments and medications, as well as billing for products and services not provided at all. In this recent Takedown, more than 170 defendants were charged for schemes related to medical necessity and up-charging. In total, more than $1.84 billion of false and fraudulent claims allegedly were made to Medicare, Medicaid and private insurance for medically unnecessary visits, testing and treatments. Similarly, DOJ pursued fraud related to telemedicine, an area that experienced a boom during the pandemic and has only continued to grow. DOJ reported that more than 49 defendants were charged with submitting more than $1.17 billion in fraudulent claims to Medicare tied to telemedicine and genetic testing fraud schemes.
Advanced technologies, which agencies are sharing, make it easier for the government to assess large swaths of data to identify outliers that suggest potential fraudulent activity. These technologies continue to get better and, therefore, likely will only become more common place within enforcement.
Conclusion
The Takedown is a reminder of law enforcement’s commitment to prosecute health care fraud. In order to stay out of the AIs of enforcement agencies, American health care providers and companies need to establish and maintain compliance programs designed to identify and prevent potential fraud.
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