Dive Brief:
- The Department of Justice and federal and state law enforcement agencies have charged 78 people across 16 states for $2.5 billion of attempted healthcare fraud and opioid abuse schemes that officials say targeted the elderly and disabled as well as HIV and opioid patients.
- The charges announced Wednesday include allegations of telemedicine schemes in which defendants submitted more than $2 billion in fraudulent claims to Medicare for reimbursement, including orders for orthopedic braces for patients whose limbs had already been amputated.
- The multi-state bust represents “one of the largest healthcare fraud schemes ever prosecuted by the Justice Department,” Attorney General Merrick Garland said in a statement.
Dive Insight:
Last year was the fourteenth consecutive year the DOJ recovered over $2 billion in False Claim Act settlements and judgments from fraud related to Medicare, Medicaid and TRICARE, according to law firm Rivkin Radler.
Still, rampant fraud has proven difficult to curtail, despite federal and state agencies’ efforts to identify and remove bad actors from the industry. Omar Pérez Aybar, special agent at the HHS’ Office of Inspector General in Florida, told CNBC earlier this year that addressing healthcare fraud feels “almost like the game of whack-a-mole, where we hit one and another pops up.”
Part of the problem, according to experts, is that fraud is easy to perform and can be difficult to detect. In 2016, the Government Accountability Office found that most fraudulent activity was performed by providers and appeared to be legitimate transactions.
Patients may not have the education to thoroughly read bills and notice improper unbundling of services (i.e., providers billing separately for overlapping services or sectioning a single procedure into multiple claims), upcoding or billing for services never performed, experts say.
Meanwhile, watchdogs and whistleblowers can only observe so much, as Medicare processes millions of claims each day.
This announcement marks one of the largest healthcare schemes prosecuted to date, but healthcare fraud is still a $100 billion dollar problem.
