Two-State Healthcare Fraud Enforcement Operation Uncovers More Than $160 Million in Medicare and Medicaid Fraudulent Billings
The Justice Department recently announced that a significant health care fraud enforcement operation across Florida and Georgia resulted in charges against 67 individuals from four federal districts for their alleged involvement in various schemes to defraud Medicare and Medicaid. The conduct of those charged involves alleged fraudulent billings of more than $160 million. Physicians, as well as other medical and business professionals, were among those charged. Additionally, another 16 defendants in the state of Florida, including one licensed mental health professional, have been charged with defrauding the Medicaid program out of over $1.2 million. Florida’s Medicaid Fraud Control Unit (MFCU) investigated these cases.
The charges aggressively target schemes alleged to have billed Medicare, Medicaid, and private insurance companies for medically unnecessary services, such as home health, prescription drugs, and durable medical equipment.
The schemes perpetrated included offenses such as stealing and selling individually identifiable health information; acquiring a controlled substance (oxycodone) through misrepresentation, fraud, or forgery; filling prescriptions for controlled substances known to be for illegitimate purposes; submission of fraudulent claims to Medicare, Medicaid, and other insurance providers; aggravated identity theft; soliciting and receiving kickback payments for Medicare beneficiary referrals; unlicensed therapist’s fraudulent Medicare billings; wire fraud; and money laundering.
The charges against the defendants are being handled by U.S. Attorneys from districts across Florida and Georgia.
Compliance Perspective
Facilities that fail to require physicians, pharmacies, or other service providers to complete a contract that affirms their compliance with state and federal regulations, and facilities that participate in kickback schemes by providing Medicare or Medicaid beneficiary referrals, might be in violation of federal and state fraud, waste, and abuse regulations and violation of anti-kickback statutes.
Discussion Points:
- Review policies and procedures regarding prohibiting receiving or providing kickbacks as well as healthcare service providers’ contracts to ensure that they include the requirements for compliance with state and federal regulations.
- Train all personnel about the facility’s policy against participating in any type of kickback scheme (including gifts from residents or their families), and how to report suspected schemes to their supervisor or through the hotline.
- Periodically audit by interviewing staff, residents, and family members about the facility’s policy against solicitation from a staff member or from a resident/family member. Periodically communicate the facility’s policy regarding “gifts” and solicitation for preferential treatment at a Residents’ Council Meeting.
