Health Care Fraud and Abuse

Abstract

In Texas, a supplier of durable medical equipment was found guilty of five counts of healthcare fraud due to submission of false claims to Medicare. The court sentenced the supplier to 120 months of incarceration and restitution of $1.6 million.1 Raritan Bay Medical Center agreed to pay the government $7.5 million to settle allegations that it defrauded the Medicare program, purposely inflating charges for inpatient and outpatient care, artificially obtaining outlier payments from Medicare.2 AmeriGroup Illinois, Inc., fraudulently skewed enrollment into the Medicaid HMO program by refusing to register pregnant women and discouraging registration for individuals with preexisting conditions. Under the False Claims Act and the Illinois Whistleblower Reward and Protection Act, AmeriGroup paid $144 million in damages to Illinois and the U.S. government and $190 million in civil penalties.3 In Florida, a dermatologist was sentenced to 22 years in prison, paid $3.7 million in restitution, forfeited an addition $3.7 million, and paid a $25,000 fine for performing 3,086 medically unnecessary surgeries on 865 Medicare beneficiaries.4 In Florida, a physician was sentenced to 24 months incarceration, ordered to pay $727,000 in restitution for cash payments where the physician signed blank prescriptions and certificates for medical necessity for patients he never saw.5 The U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) found that providers in 8 out of 10 audited states received an estimated total of $27.3 million in Medicaid overpayments for services claimed after beneficiaries' deaths.6