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Justice, HHS join forces to tackle health care fraud

Jun. 17, 2010 - 06:00AM   |  
By TIM KAUFFMAN   |   Comments
Assistant Deputy Attorney General Edward Siskel, right, says the effort to significantly cut improper Medicare payouts has produced results.
Assistant Deputy Attorney General Edward Siskel, right, says the effort to significantly cut improper Medicare payouts has produced results. (Sheila Vemmer / Staff)

A year-old team of Justice and Health and Human Services department investigators is making a dent in collecting and preventing improper payouts under the Medicare program, which is responsible for roughly half of the government's $100 billion in improper payments annually.

Dubbed the Health Care Fraud Prevention and Enforcement Action Team, or HEAT, the initiative has produced substantial results in combating waste, fraud and abuse in the Medicare and Medicaid programs, which HHS manages, said Edward Siskel, associate deputy attorney general at Justice. Medicare claims and payouts for medical equipment used in the home one of the areas most susceptible to fraud declined significantly after authorities increased arrests and prosecutions in one hot-spot area, South Florida.

"We have seen that these enforcement actions have a significant deterrent effect," Siskel testified Tuesday before the House Ways and Means subcommittees on health and oversight.

The HEAT initiative has expedited health care fraud criminal investigations and legal prosecutions by using a strike force model, in which teams of investigators are dispatched to areas with higher than normal levels of unexplained Medicare billing activity. These strike force teams currently are in seven locations: South Florida; Los Angeles; Detroit; Houston; Brooklyn, N.Y.; Baton Rouge, La.; and Tampa, Fla.

The Obama administration is seeking an additional $250 million in discretionary funding for the HEAT program in the fiscal 2011 budget, which would allow the number of teams to be expanded to 20 by the end of 2012, Siskel said.

The additional resources would help the agencies meet a recent White House directive to cut in half by 2012 the rate of improper payments to doctors and other care providers treating Medicare patients.

In just over a year's time, prosecutors have filed more than 120 cases in the strike team locations charging more than 290 defendants with Medicare-related crimes, negotiated about 130 guilty pleas and obtained convictions of 16 defendants from 12 jury trials.

In addition to criminal enforcement, the HEAT initiative focuses on civil enforcement of Medicare laws under the False Claims Act, Anti-Kickback Act and Food, Drug and Cosmetic Act. During fiscal 2009, Justice announced $1.6 billion in civil settlements and judgments.

In addition, Pfizer agreed last fall to pay $2.3 billion to resolve criminal and civil liability claims arising from the illegal promotion of certain prescription drugs. The Pfizer payout is the largest criminal fine ever imposed in the U.S. and the largest ever civil fraud settlement against a pharmaceutical company

Since 1997, when Congress established the Health Care Fraud and Abuse Control Program to coordinate federal and local law enforcement efforts, $15.6 billion has been recovered and returned to the Medicare Trust Fund. Every dollar that's been invested in the program has returned $4 to the trust fund, Siskel said.

More needs to be done

Still, the Centers for Medicare and Medicaid Services could do more to prevent fraud, said Rep. Lloyd Doggett, D-Texas.

The agency has failed to remove Social Security numbers from Medicare insurance cards leaving many of the 45 million beneficiaries vulnerable to identify theft, he said.

Lawmakers and administration officials have been pressing the agency for years to remove Social Security numbers from the cards, yet the agency seems to be no closer to achieving that goal, Doggett said.

"The main thing CMS has done is to come up with astronomical implementation costs that seek to deter legislative action," he said.

Kimberly Brandt, the CMS official who testified at last week's hearing, said she believes the agency remains committed to protecting beneficiaries against identity theft.

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