$452 Million Dollar Medicare Bust

Is your practice meeting the rules of TEFRA if the MDAs are billing "medical direction"? If not this could be your group.


Officials busted 107 individuals, charged with $452 million worth of Medicare billing fraud, the U.S. Justice Department and Health & Human Services announced yesterday. The multi-million value is one of the highest amounts in bogus billings in a single takedown by the Medicare Strike Force.


In addition to healthcare fraud and conspiracy to commit healthcare fraud, the alleged schemes include money laundering and kickback violations in seven out of the nine cities the Medicare Strike Force monitors: Miami; Tampa; Houston; Baton Rouge, La.; Los Angeles; Chicago and Detroit.


In Baton Rouge, La., defendants allegedly recruited beneficiaries from nursing homes and homeless shelters--some who were addicted to drugs or mentally ill--and didn't provide them with services or provided medically inappropriate services, Assistant Attorney General Lanny Breuer said yesterday. To cover up the scam, they allegedly falsified patient notes and attendance records and forged medical professionals' signatures. Some of the defendants even went as far as to steal incriminating documents from the U.S. Attorney's Office and had torched the fake patient notes in a bonfire, according to court documents. It's the largest false claims case involving community mental health centers that the Strike Force has ever prosecuted.


In Houston, ambulance company owners and operators allegedly billed Medicare for millions of dollars for ambulance rides that were medically unnecessary or outright fake.


In Detroit, authorities charged social workers in billing for medically unnecessary services, including home health, psychotherapy and infusion therapy.


The indictments reveal that fraudsters are present throughout the chain of command, as Breuer noted. Those charged include the spectrum of providers and caregivers, including physicians, nurses, social workers, healthcare company owners, office managers and patient recruiters.


Attorney General Eric Holder attributed the results to its "ongoing fight against healthcare fraud [which] has never been more coordinated and effective." As the fourth landmark Medicare fraud takedown in the past two years, it's clear that authorities are concentrating their efforts on stopping criminals in their tracks.


HHS is exercising its new authority under the Affordable Care Act in which it can suspend payments until an investigation is complete. HHS Secretary Kathleen Sebelius said the agency applied that authority on 52 providers, using data-driven analysis and credible allegations of fraud.


"The results we are announcing today are at the heart of an administration-wide commitment to protecting American taxpayers from healthcare fraud, which can drive up costs and threaten the strength and integrity of our healthcare system," said Attorney General Holder. "We are determined to bring to justice those who violate our laws and defraud the Medicare program for personal gain.