A recent nationwide investigation has made history, involving more than 300 charged defendants across 51 federal districts, and including more than 100 licensed medical professionals.
According to the Drug Enforcement Administration (DEA), the defendants are being charged with “submitting more than $6 billion in false and fraudulent claims to federal health care programs and private insurers.”
This includes:
More than $4.5 billion connected to telemedicine
More than $845 million connected to substance abuse treatment facilities, or “sober homes
More than $806 million connected to other health care fraud and illegal opioid distribution schemes across the country
While the size and scope of this investigation make it unprecedented, it also makes it a little scary. How could fraud on this scale exist, and how can you trust the system to protect your company and employees?
“These cases hold accountable those medical professionals and others who have exploited health care benefit programs and patients for personal gain,” said Acting Assistant Attorney General Brian C. Rabbitt of the Justice Department’s Criminal Division in a press release. He also stated they will “send a clear deterrent message” and reinforce “the department’s ongoing commitment to ensuring the safety of patients and the integrity of health benefit programs, even amid a national health emergency.”
Breaking It Down: Telemedicine
The largest chunk of money involved was connected to telemedicine. It involved more than 86 defendants in 19 judicial districts. “Actors attempt to abuse telemedicine services and leverage aggressive marketing techniques to mislead beneficiaries about their health care needs and bill the government for illegitimate services,” said HHS Deputy Inspector General Gary Cantrell.
Substance Abuse and “Sober Homes”
The charges include physicians, owners/operators of substance abuse facilities, as well as patient recruiters. The individuals are alleged to have participated in illegal kickbacks, bribes for referrals and fraudulent claims, as well as prescribing unnecessary controlled substances to patients – sometimes to entice them to remain at the facility.
Illegal Prescription and/or Distribution of Opioids
These cases involve more than 240 defendants, who allegedly aided in schemes to supply beneficiary information to providers so providers could submit fraudulent bills to Medicare. Charges also included the distribution of more than 30 million doses of opioids and other prescriptions narcotics.
Though much of our news has since centered around the pandemic, opioid abuse is still prevalent. DEA Assistant Administrator Tim McDermott explained “the opioid epidemic our country is battling is exacerbated when unscrupulous individuals seek to profit from people, in particular those confronting addiction.”
So, What Does This Mean?
This is a major win in the fight against health care fraud and opioid abuse, however, it remains an ongoing issue. The Department of Justice announced, in connection with the recent investigation, the creation of the National Rapid Response Strike Force of the Health Care Fraud Unit of the Criminal Division’s Fraud Section. According to the DEA, their “mission is to investigate and prosecute fraud cases involving major care providers that operate in multiple jurisdictions.”
While the sheer numbers of this investigation can be disheartening and worrisome, investigations like this, along with new DEA efforts, will continue to help identify fraud and protect the millions of people who rely on federal health programs. For employers that self-fund their health plan, ensuring proper oversight and claim adjudication processes are an essential function to preventing fraud and abuse.
