Despite the fact that nearly six months remain, 2016 has already proven itself to be a record year with respect to the number of health insurance fraud claims filed. In 2015, the federal Department of Justice (DOJ) charged some 243 defendants with insurance fraud, claiming it had lost $712 million from those crimes. See Joshua Roberts, “U.S. completes ‘takedown’ of Medicare fraud: Officials,” Reuters, Jun. 22, 2016. This year, however, federal “law enforcement officials have charged 301 suspects with trying to defraud Medicare and other federal insurance programs in 2016, marking the “largest takedown” involving health care fraud allegations.” Id. This article discusses the types of cases that are being filed and the role that medical fraud expert witnesses play in this process.
According to the DOJ, the charges it has made concern a variety of matters. See id. Several of the matters that have allegedly occurred are described and discussed as follows.
(1). Compounding Prescriptions: According to the federal government, it paid $1.75 billion in 2015 for compounded prescriptions. See Scott R. Grubman, et al., “Compounding the Problem: The Government Cracks Down on Compounding Pharmacy Fraud and Abuse,” American Bar Association, Apr. 2015-2016. Compounding occurs when a healthcare professional “combines, mixes, or alters ingredients of a drug to create a medication tailored to the needs of an individual patient.” Id., citing FDA.gov, “Compounding and the FDA: Questions and Answers,” http://www.fda.gov/Drugs/Guidance ComplianceRegulatoryInformation/PharmacyCompounding/ucm339764.htm. The government has expressed concern about an increase in healthcare fraud cases that involve compounding. See Roberts, supra. One issue with compounded prescriptions is that vast overbilling has occurred. Another involves medical practitioners creating or requesting a compounded prescription when it is not medically necessary, in order to justify a higher level of reimbursement for a customized medication. Of late, there have also been several concerns over doctors sending medications to compounding pharmacies in exchange for certain kickbacks.
In fraud cases within the healthcare industry based upon compounding, medical fraud expert witnesses play a critical role. For example, medical billing experts can establish several important facts, such as what the appropriate charge/market rate should be for a compounded prescription for reimbursement purposes. In addition, medical experts such as physicians and insurance experts may be able to help determine whether a compounded prescription is medically necessary or not. This is particularly important, as the False Claims Act (FCA) prohibits billing for items that are not medical necessities. See Grubman, et al., supra.
(2). Fraudulent Billing & Identity Theft: Many cases of healthcare fraud are currently of two types: (1). patient identity theft, and (2). professional (typically doctors) identity theft.so I
(A). Patients: Patient-based fraud can be very difficult to detect, particularly among patients who receive subsidized healthcare, because many patients may simply not notice what services their insurance was billed for. The DOJ recently discussed two cases in which identity-based fraud occurred with patients. In one instance, a chain of clinics and a patient recruiter allegedly filed “$36 million in fraudulent claims for physical therapy and other services that were not medically necessary.” Roberts, supra. In another instance, some clinic operators and a recruiter were alleged to have “targeted poor drug addicts and offered them narcotics so they could bill them for services that were never provided.” Id. The Federal Bureau of Investigation (FBI) has also enumerated several other scenarios in which patient information can be stolen and used to commit healthcare fraud. For instance, the FBI claims that some of the most common situations where such crimes occur involve: “Providing an inducement, such as money or a gift, to beneficiaries to visit a location (normally medical clinics) where identities are obtained when the patient signs in”; “Obtaining patient information when patients obtain a free screening”; Inducing medical personnel with access to patient insurance information to copy the material and provide it to those involved in fraud schemes”; and “Purchasing the information from others involved in fraud, including owners of fraudulent companies and marketers of stolen patient and physician billing information.” Federal Bureau of Investigation, “Health Care Fraud Overview,” https://www.fbi.gov/about-us/investigate/white_collar/health-care-fraud/health-care-overview (last visited Jun. 23 2016).
In instances of alleged patient-based identity theft, medical fraud expert witnesses can help to determine whether fraud occurred. Some of the experts who can assist in this vein are identity theft experts, medical billing experts, and doctors and clinicians who can speak to what the accepted professional practices and standards of care are in a particular field.
(B). Medical Professionals: Doctors and other medical providers also face a risk of having their identities and credentials stolen and fraudulently used. For example, one physician reported to the FBI that “her identity and medical credentials were used without her permission to fill thousands of dollars worth of prescriptions.” In other cases, individuals have purportedly practiced medicine by either using another person’s identity or by simply misrepresenting themselves as being medical professionals. Roberts, supra. In such cases, medical fraud expert witnesses can be extremely valuable. In addition to medical fraud experts, medical billing and coding experts, and other medical professionals can help to establish whether a case of identity theft exists in these instances.
Healthcare fraud claims are on the rise, and the federal claims for the past six months has already surpassed the number of charges filed for all of 2015. With such litigation on the rise, it will be up to healthcare attorneys and medical fraud expert witnesses to help establish the facts in this highly litigious field.
By: Kat S. Hatziavramidis, Attorney-at-Law