Wanted: Dead or Alive

Of the many, many different criticisms I have heard regarding our current health care system and the PPACA in particular is that it does not do enough to contain costs. Medicare alone accounts for a staggering amount of overage, and clearly if our health care system is to be improved, so say the critics, then something must be done about Medicare at the very least.

It is a valid argument. The degree of waste and outright fraud that occurs under Medicare is staggering. Which is probably why at the beginning of the year, the Department of Health and Human Services, under Secretary Kathleen Sebelius (who has faced a slew of lawsuits over the healthcare mandate ever since PPACA passed, by the way) has held a series of health care fraud prevention summits. The third such summit was held in Brooklyn, NY this morning and covered a range of efforts to address the problem.

On one front, you’ve got law enforcement agencies at the state and federal levels working hard to crack organized crime rings that are bilking the system for millions upon millions each year. Representatives from those agencies spoke of major cases this year. In one case, the Medicare strike force known as HEAT (Health Care Fraud Prevention and Enforcement Action Team) took down a ring that had fraudulently billed more than $160 million in bogus claims. Another recent case stopped an $80 million ring consisting of more than 90 individuals. All told, in the last fical year alone, explained Sebelius, HEAT opened more than 2,000 civil and criminal fraud investigations, stopped numerous schemes, returned more than $2.5 billion to the Medicare fund and more than $800 million to cash-strapped state funds.

On a second front, you’ve got the judicial element doing what it can to seek tougher penalties for those who do defraud the system in general, but especially Medicare, which falls under federal jurisdiction. Prosecutors are using a wide range of options to raise the stakes for committing health care fraud. For starters, they are pressing charges against medical professionals who knowingly perform unneeded medical services (after all, every health care fraud ring needs at least one complicit doctor), in addition to going after the familiar targets of patient recruiters and patients themselves. Longer sentences are also being sought, with cases this year handing down twenty- or thirty-year stretches for more than a few ringleaders of fraud gangs. Granted, there are violent drug offenders who are getting less harsh sentences, but that’s more reason to punish those bastards more severely, rather than ratchet back the penalties for fraud.

Of special interest is how prosecutors are invoking laws against money laundering and even hate crimes to widen what kinds fo cases they can prosecute, and to deepen the severity of those cases. This last example was used in a case where a professional ring of fraudsters was targeting Asian drivers and getting into intentional car accidents with them. The modus operandi was for the fraudsters to then claim bogus injuries against Medicare, all while claiming the victims caused the accidents. While nobody explicitly said so, one was left to imagine that the hate crime angle was used perhaps because the criminal enterprise was meant, in large part, to play on ugly stereotypes about Asian drivers. But even if not, the use of hate crime law to prosecute those targeting ethnic groups of any kind is an interesting development, and one sure to turn the heat up on fraudsters.

But what I found most compelling was the civil side of fraud prevention, where medical providers and health care patients themselves can take an active role in spotting fraud as it happens and blow the whistle on it. Seniors are being actively encouraged to drop a dime on any suspicious Medicare activity they see, and they’ve got plenty of motivation too, since any wrongdoing is only bleeding out a system they are already relying on to deliver medical care. But some of the most hair-curling stories of health care fraud were coming from the corporate front; tales by prosecutors and law enforcement officials of pharmaceutical companies aggressively selling drugs they knew either did not work or were wrong for certain patients, but were pushed anyway to offset their meager legitimate sales. Another story involved a dental clinic that had made a practice of pushing unneeded dental care on Medicare patients less than 10 years old, or on medical clinics that provided kickbacks to local homeless shelters who sent otherwise healthy people for medical procedures they did not need, and were later deposited back on the streets in a post-anasthetic daze.