Government healthcare fraud investigations show no sign of slowing

Billions recovered in healthcare fraud investigations in 2014.

In March, the Justice Department and Health and Human Services released a report that U.S. investigative efforts to combat health care fraud netted the government $3.3 billion in fiscal year 2014.

In Washington, money talks. And the government's return on investment of over $7 per dollar spent investigating healthcare fraud is a return that will lead to more investigations. HHS Secretary Sylvia Mathews Burwell said in a statement released with the report that "these impressive recoveries . . . highlight our efforts to prosecute the most egregious instances of health-care fraud and prevent future fraud and abuse."

The report also indicated that a predictive analysis program, the Fraud Prevention System, has been successful in identifying unusual fee-for-service claims in the medical industry. That system alone led to 469 investigations nationwide in 2013 and identified approximately $211 million in "improper" payments.

According to an investigation by The Wall Street Journal, up to 10 percent of Medicare spending involves fraud. However, exact data is difficult to come by, and it is not clear how much undetected fraud is actually occurring.

Under investigation?

Of course, not every "improper payment" is an indication of Medicare, Medicaid or health care fraud. Billing codes for Medicare can be notoriously difficult, and honest mistakes can easily lead to an investigation if it raises a red flag in the Fraud Prevention System. Still, in the last several years, the government has invested more in investigations, leading to greater monetary recovery, leading to more investigations . . . and this escalating circle shows no signs of slowing.

The implementation of the Affordable Care Act, which mandates fraud investigations, has also led to increased spending on healthcare fraud investigations. The ACA has dedicated $350 million in funding to combat health care fraud through 2020. In 2014, the Department of Justice opened 77 new criminal fraud investigations every month. That does not include civil lawsuits regarding improper health care billing or individual state investigations.

At Nathans & Biddle, LLP our attorneys understand the nuances involved in healthcare fraud investigations and allegations of improper billing. Just because a healthcare provider has not committed fraud does not mean the DOJ will not begin an investigation. The DOJ also has significant authority when conducting a fraud investigation. The DOJ may freeze accounts, seize property it deems related to the alleged fraud, and freeze any reimbursements. This can be true regardless of the outcome of the investigation or criminal charges.

If you may be under investigation for healthcare fraud, do not delay in speaking to a criminal defense attorney experienced with healthcare fraud investigations to begin mounting a defense against these serious charges.

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