The Department of Justice recently announced the results of its 2020 National Health Care Fraud and Opioid Takedown. This annual DOJ tradition, aimed at targeting and arresting individuals for health care fraud abuse, resulted in the filing of criminal charges against more than 50 doctors and more than 20 health care executives. Prosecutions spanned the country, including more than 50 federal districts and 40 U.S. Attorney’s Offices. FY2020’s efforts represent “the largest amount of fraud ever charged by the department in a single National Takedown.”
Despite the pandemic, or maybe because of it, telemedicine services represented the largest amount of fraud charged in FY2020. Fraudulent schemes in the Takedown included billing for medically unnecessary treatments and medications, as well as billing for products and services not provided at all. Also prominent were charges for fraud related to substance abuse treatment centers, or so-called “sober homes.” DOJ further charged “doctors, lab owners, and others responsible” for the illegal prescription and distribution of opioids. In a companion action, the Centers for Medicare and Medicaid Services (CMS) revoked more than 250 billing privileges for Medicare and Medicaid.
The DOJ also announced the creation of a new National Rapid Response Strike Force based out of Washington, D.C. This new investigatory body is part of the existing Health Care Fraud Criminal Division and works collaboratively with existing fraud units throughout the country. The Strike Force is intended to address larger “multi-district fraud schemes”—which can occur with larger health care systems and pharmaceutical companies. The Strike Force also will expand upon the DOJ’s data-mining expertise and use data analytics as a key tool in identifying fraud.
With the recent distribution of $175 billion in Provider Relief Funds, it is probable that the DOJ will use its enhanced data analytics to identify potential fraudulent trends and practices by providers in receipt of those funds. It is essential that providers timely account and fully report all PRF spending in accordance with the HHS guidelines. Providers receiving larger PRF grants in comparison to peer providers, those receiving targeted distributions, and those providing care in areas hit either the most or the least by the coronavirus may appear as outliers, and therefore should pay particular attention to both the manner in which the funds are used and their reporting obligations.
Healthcare providers who bill federal health care programs need to continue to scrutinize their billing practices. Compliance efforts should take into account the government’s data-mining functions in order to spot billing issues before they develop into federal criminal problems.
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