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Medicare Fraud Strike Force Successful with “Big Data” Detection Methods.

October 27, 2016

In a story reported by The Fiscal Times, U.S. customs officials arrested a woman at the Dallas-Fort Worth International Airport mid October, 2016, who is suspected of involvement in one of the biggest Medicare fraud schemes in history. This bust is another record-breaking fraud scheme that found its end as part of the Obama administration’s crackdown on Medicare fraud,

As Eric Pianin reported for The Fiscal Times, (http://www.thefiscaltimes.com/2016/10/23/Crackdown-Medicare-Fraud-Producing-Some-Impressive-Results) “The suspect, Lidia Antonio, 57, is one of a dozen people from the Dallas-Fort Worth area suspected of taking part in a nationwide scam to defraud Medicare of $900 million, according to U.S. Attorney General Loretta Lynch. They did it, among other ways, by billing for bogus ear care procedures purportedly done on elderly nursing home patients, including some who were unconscious. Some health care providers offered kickbacks to “patient recruiters” to help assemble bogus patient information.

The government’s Medicare Fraud Strike Force investigation of the scam has resulted in the arrests of 301 people across the country, including 61 doctors, nurses and other medical professionals. If convicted, Antonio faces a maximum of 10 years in prison and a $250,000 fine, according to The Dallas Morning News.

After years of losing tens of billions of dollars through Medicare fraud, Justice Department and Health and Human Services officials, the FBI, government agency inspectors general, auditors and others have made important headway in slamming the door on fraudulent activities by doctors, hospitals, nursing home facilities, recruiters and conspiring patients.

At the beginning of his second term, President Obama made combatting Medicare and Medicaid fraud a top priority – a decision that has led to a series of high-profile arrests and prosecutions by federal and state law enforcement agencies.

Last June, the administration notified Congress that it had prevented $42 billion of improper payments to doctors and other medical providers in fiscal 2013 and 2014 by using more sophisticated “big data” detection methods.

Since 2010, the administration’s fraud taskforce has arrested and prosecuted about 1,200 people allegedly involved in defrauding Medicare and Medicaid of more than $3.5 billion, according to the Justice Department.

The government now routinely collects billions of dollars annually in settlements and judgments against hospitals, nursing homes, drug companies, medical suppliers and physicians, Washlick noted, with each year’s recoveries exceeding those of the previous record-setting year.

There was a time when the government responded to Medicare fraud with a slap on the hand and a fine, but those days are over. Now, many more individuals are being prosecuted on criminal charges and sentenced to significant jail terms for their involvement in schemes designed to pay kickbacks for referrals or other business.

The Inspector General’s office for Health and Human Services and other government watchdog agencies have also been helped significantly by provisions of the 2010 Affordable Care Act.

The Obamacare law provides resources for combatting Medicare fraud and requires anyone who has knowledge that they are in receipt of federal overpayments in violation of federal anti-kickback laws to report that to authorities within 60 days. If they don’t, they face penalties, prosecution or disbarment from the federal health programs. Moreover, any individual within a health care organization can blow the whistle on wrongdoers and share in a bounty of up to 25 percent of whatever is collected by the government.

Even so, enforcement agencies are woefully understaffed and underfunded given the volume of fraudulent schemes that seems to keep growing, according to Washlick.”

Susen Sawatzki Written by Susen Sawatzki
Healthcare Industry Expert
Muse. Writer. Publisher. Producer. Creator of Inspiring Narratives.
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