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Investigating Medicare Fraud: How the Government and Law Enforcement Work to Combat Fraud

March 27, 2023

As healthcare costs continue to rise, Medicare fraud has become a major concern for both the government and taxpayers. Medicare fraud occurs when healthcare providers or individuals intentionally submit false or misleading information to Medicare in order to receive payments that they are not entitled to. This can include billing for services that were never provided, upcoding services to receive a higher reimbursement rate, and the use of kickbacks to steer patients to their practice.

Government Initiatives to Combat Medicare Fraud

The government has taken steps to combat Medicare fraud by implementing various laws, regulations, and initiatives. One of the major initiatives is the Health Care Fraud and Abuse Control (HCFAC) program, which was established in 1996. The HCFAC program is a joint effort between the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) to combat healthcare fraud. The program works by coordinating federal, state, and local law enforcement efforts to investigate and prosecute healthcare fraud cases.

However, initiatives by themselves are groundless unless the government has a gateway to information to unearth the considerable amount of fraud that goes on. Enter the False Claims Act (“FCA”), a statute that has been a powerful tool in combating Medicare fraud, which is estimated to cost taxpayers billions of dollars each year. Under the False Claims Act, whistleblowers who report fraudulent billing practices to the government can receive a percentage of the recovered funds. This has incentivized individuals with knowledge of Medicare fraud to come forward and report wrongdoing.

As a result, the government has been able to recover significant amounts of money from healthcare providers who have defrauded Medicare. The False Claims Act has also allowed the government to bring legal action against companies and individuals who have violated the law, resulting in large fines and other penalties. The Act has been instrumental in protecting the integrity of the Medicare system and ensuring that healthcare providers are held accountable for their actions.

Recent settlements show that the government is committed to prosecuting those who engage in Medicare fraud. In 2019, a pharmacy and its owner agreed to pay $21.36 million to resolve allegations of submitting false claims to Medicare. Also in 2019, Sutter Health agreed to pay $30 million to settle allegations that it submitted inaccurate information about the health status of patients enrolled in its Medicare Advantage plans.

The HCFAC program has been successful in identifying and prosecuting healthcare fraud cases. In 2019, the DOJ announced that it had recovered $3.6 billion in healthcare fraud judgments and settlements, with $2.5 billion coming from cases involving false claims submitted to Medicare and Medicaid. The program also works to prevent healthcare fraud by providing education and outreach to healthcare providers, patients, and the public.

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Recent Whistleblower Settlements

One example of a recent settlement involving Medicare fraud is the case of United States ex rel. Medrano and Lopez v. Diabetic Care Rx, LLC. In this case, a pharmacy and its owner were accused of submitting false claims to Medicare for medically unnecessary prescriptions. The pharmacy and its owner agreed to pay $21.36 million to resolve the allegations, which under the FCA generates a whistleblower award of roughly $4 million for doing the right thing

Another recent settlement involved the healthcare company, Sutter Health. In 2019, Sutter Health agreed to pay $30 million to settle allegations that it submitted inaccurate information about the health status of patients enrolled in its Medicare Advantage plans. The settlement resolved a lawsuit filed by a whistleblower who alleged that Sutter Health submitted unsupported diagnoses to Medicare in order to receive higher payments which using a 20% whistleblower reward as a barometer made available roughly a $6 million award

Whistleblower Awards

If you are looking to blow the whistle on Medicare fraud, it is best to speak with a Medicare fraud whistleblower law firm. If you go directly to the government without commencing an False Claims Act qui tam lawsuit, you will not be eligible for whistleblower award. Whistleblower Law Firms like Brown, LLC can help you navigate the complexities of the legal system, protect your rights, and help you try to obtain the reward you deserve. 

How the government combats Medicare Fraud.

Other Government Initiatives to Combat Medicare Fraud

The government has also implemented other initiatives to combat Medicare fraud. One such initiative is the Medicare Fraud Strike Force, which was established in 2007. The Strike Force is a joint effort between the DOJ and HHS to target and prosecute healthcare fraud in nine regions across the country.

The government has also taken steps to educate the public about Medicare fraud and how to prevent it. The Senior Medicare Patrol (SMP) program is a national program that trains volunteers to educate and empower Medicare beneficiaries to prevent, detect, and report healthcare fraud. The program has been successful in identifying and preventing Medicare fraud and has saved taxpayers millions of dollars.

In addition to these measures, the government is also working to improve the transparency and accountability of the Medicare program. The Affordable Care Act (ACA) included several provisions to improve the integrity of the Medicare program. For example, the ACA established new screening and enrollment requirements for providers and suppliers, and increased penalties for those who engage in fraudulent activities.

Challenges in Combating Medicare Fraud

However, despite these efforts, Medicare fraud continues to be a significant problem. In 2018, the DOJ announced that it had charged over 600 defendants in healthcare fraud cases, including 165 doctors, nurses, and other medical professionals. The cases involved over $2 billion in losses to Medicare and Medicaid.

One of the challenges in combating Medicare fraud is the complexity of the healthcare system. Medicare fraud can involve multiple parties, including healthcare providers, patients, and third-party billing companies. In addition, Medicare fraud can take many different forms, such as billing for unnecessary services or equipment, overcharging for services, and even prescribing unnecessary medications. This is why it’s important to talk to law firms who are experienced in handling whistleblower cases who can guide you in every step of the process.

Future of Combating Medicare Fraud

Despite these challenges, the government and law enforcement agencies are continuing to work to combat Medicare fraud. In 2019, the DOJ announced the creation of the National Rapid Response Strike Force, which is designed to respond quickly to suspected healthcare fraud schemes and will focus on investigating and prosecuting fraud schemes that threaten public health or patient safety.

Recent initiatives, such as the National Rapid Response Strike Force, implemented by the DOJ in 2019, are designed to respond quickly to suspected healthcare fraud schemes. While Medicare fraud continues to be a significant problem, the government and law enforcement agencies are continuing to work to combat it, and the public can also play a role in preventing Medicare fraud by reporting any suspicious activity to the appropriate authorities.

While the government has implemented various laws, regulations, and initiatives to combat Medicare fraud, more needs to be done to adequately address the issue. This includes investing more resources into healthcare fraud investigations and prosecutions, increasing penalties for fraudulent behavior, and improving coordination and communication between government agencies and departments.

Medicare fraud is a serious issue that affects both the government and taxpayers. The government has taken steps to combat Medicare fraud by implementing various laws, regulations, and initiatives, such as the HCFAC program and the Medicare Fraud Strike Force. Recent settlements, such as those involving Diabetic Care Rx, LLC and Sutter Health, show that the government is committed to prosecuting those who engage in Medicare fraud. The public can also play a role in preventing Medicare fraud by being aware of the issue and reporting any suspicious activity to the appropriate authorities. However, more needs to be done to address the challenges associated with investigating and prosecuting Medicare fraud, and to ensure that taxpayer dollars are used appropriately to provide healthcare services to those who need them.

  • “Justice Department Recovers Over $3 Billion from False Claims Act Cases in Fiscal Year 2019.” Department of Justice. (2019). https://www.justice.gov/opa/pr/justice-department-recovers-over-3-billion-false-claims-act-cases-fiscal-year-2019
  • “United States Settles False Claims Act Allegations Against Diabetic Care Rx LLC and Patient Care America.” https://www.justice.gov/opa/pr/compounding-pharmacy-two-its-executives-and-private-equity-firm-agree-pay-2136-million
  • “Sutter Health to Pay $30 Million to Resolve Allegations of Miscalculating Medicare Advantage Risk Scores.” https://www.justice.gov/usao-ndca/pr/medicare-advantage-provider-pay-30-million-settle-alleged-overpayment-medicare
  • “Health Care Fraud and Abuse Control Program Report.” https://oig.hhs.gov/publications/docs/hcfac/FY2019-hcfac.pdf