It is estimated that the government loses up to $250 billion annually in healthcare fraud. At face value, this figure seems exaggerated. However, if you begin to look at the sheer amounts lost in individual fraud cases, then it is easy to see why the figures might add up.
Here is a list of the biggest healthcare frauds in 2015 so far. There are the biggest by the millions of dollars involved. This is a running list. So, as more fraud take-downs occur, we’ll be bringing them right here. For now, these are the largest, by virtue of their magnitude.
$712 Million Medicare Bust – 243 Indicted
On June 19th, Attorney General Loretta Lynch announced the biggest Medicare take-down in history. In a joint effort between the FBI and local authorities, there were coordinated raids across 17 US cities. A total of 243 people were arrested. Those arrested included doctors, nurses, surgeons and other health professionals.
Those arrested were charged with defrauding Medicare of up to $712 million. The fraudsters mostly billed Medicare for unnecessary or non-existent medical procedures. An example is a Los Angeles doctor who billed Medicare $23 million for supplying 1,000 wheelchairs. The problem most of the people he allegedly gave wheelchairs had no need for them, and most hadn’t received them anyway. (http://money.cnn.com/2015/06/19/pf/medicare-fraud-doctors/)
$97 Million Medicare Fraud – 7 Jailed
In January, seven people including the owners and former employees of the defunct Spectrum Care, P.A were handed jail terms ranging from 4 years to 12 years. The seven were found guilty of conspiring to defraud Medicare of up to $97 million.
It is alleged that Spectrum Care – a community mental health clinic – operated a scheme of kickbacks. The clinic offered kickbacks to home care operators and patient recruiters to refer Medicare patients to them. In most cases, the patients were actually ineligible for mental health care. In extreme cases, some patients received kickbacks.
Spectrum also billed Medicare for the time patients spent doing non-medical related activities like playing games and watching TV. These bills added up to $97 million, and the defendants ended up earning hefty jail sentences. (http://compliance.com/industry-news/owners-of-a-mental-health-clinic-sentenced-for-medicare-fraud-scheme)
$75 Million Medicaid Fraud – Settlement Reached
In February, Community Health Systems – one of the largest US hospital groups – agreed to pay $75 million to settle a False Claims Act case brought by a whistleblower. The case, which was filed in 2009 alleged that CHS defrauded Medicaid by making donations to New Mexico counties in exchange for higher Medicaid payments.
The lawsuit was initiated by Robert Baker a former revenue manager at CHS. Mr. Baker alleged that for every $1 which CMS donated, it received back $3 in Medicaid payments. In February, CMS agreed to pay the federal government $75 million in damages to settle the suit. (http://www.healthcarefinancenews.com/news/community-health-systems-pay-75-pay-whistleblower-case-over-medicaid-fraud)
$63 Million Medicare Fraud – 2 Jailed
In February, 2 Miami residents were each jailed for six years for defrauding Medicare of $63 million. The pair ran the now defunct Health Care Solutions Network (HCSN) which was presented as a mental health treatment provider. The only problem is that the HCSN had little to offer in terms of actual treatment. Its “therapies” consisted of Bingo games and Disney movies.
The Network was adept at forging medical records. It forged records of treatments, and billed Medicare for it. In certain cases, it offered kickbacks to other service providers to refer patients to them. Their scheme is believed to have cost Medicare $63 million, hence the jail sentences. (http://www.justice.gov/opa/pr/two-miami-residents-sentenced-72-months-prison-their-roles-63-million-medicare-fraud-scheme)
Basically, those are the biggest frauds of 2015 so far. Just remember, this is a running list. Therefore, as more fraudsters are busted, jailed or fined heavily, we’ll let you know right here. Watch this space!