On May 18, 2017, Acting Assistant Attorney General Kenneth A. Blanco of the Criminal Division of the Department of Justice (DOJ) addressed attendees at the American Bar Association’s 27th Annual Institute on Health Care Fraud. Early in his speech, Blanco asserted Attorney General Jeff Session’s firm commitment to fighting health care fraud:
… let me be clear: health care fraud is a priority for the Department of Justice. Attorney General Sessions feels very strongly about this. I can tell you that he has expressed this to me personally. The investigation and prosecution of health care fraud will continue; the department will be vigorous in its pursuit of those who violate the law in this area.
According to Blanco, by some estimates health care fraud costs American taxpayers a staggering $100 billion per year. However, arrayed against those who seek to defraud Medicare, Medicaid, and other federal health care programs stands a formidable array of investigators and prosecutors that are now utilizing a data-driven approach to ferreting out fraudulent schemes.
Blanco specifically cited the activities of the DOJ’s Health Care Fraud Unit, which has posted Medicare Fraud Strike Forces in nine epicenters of health care fraud across the country. The Strike Forces utilize a cross-agency approach to investigation and enforcement that includes the Criminal Division, the U.S. Attorneys Offices, the FBI, the Department of Health and Human Services Office of Inspector General (HHS-OIG), in addition to state and local law enforcement.
The numbers that the Strike Forces have put up are impressive. Since its creation in 2007, the Strike Force has charged nearly 3,200 defendants who have collectively billed over $11 billion to the Medicare program. Between early 2016 and February of 2017, Blanco noted that the program had “charged 482 individuals with a total loss amount of nearly $2.8 billion. During this period, 180 defendants were convicted, and the Medicare Fraud Strike Force reached resolutions totaling $512 million paid to U.S. and state authorities.”
Finally, in what should be an eye-opener to anyone thinking that they can slip fraudulent schemes through the system with no one the wiser, Blanco disclosed some of the investigative techniques, including extensive data-mining, which the Strike Forces are utilizing in order to reveal criminal activity. In full, Blanco stated:
In addition to many traditional methods for developing information and evidence, the Strike Forces are using highly advanced data analysis to identify aberrant billing levels in order to target suspicious billing patterns and emerging schemes. More specifically, the Medicare Fraud Strike Force is obtaining billing data from CMS in close to real time.
We now have an in-house data analytics team headed by some of the best and brightest. Analyzing billing data from CMS has become a key part of our investigations because it permits us to focus on the most aggravated cases and to identify quickly emerging schemes and new types of Medicare fraud. Access to CMS billing data in close to real time permits us to remain a step ahead. We have the opportunity to halt schemes as they develop. This cutting-edge method has truly revolutionized how we investigate and prosecute health care fraud.
What’s more is that we are pushing out the data we develop to U.S. Attorney’s Offices and investigative agencies across the country, not just our Strike Force cities. Doing so empowers other prosecutors whether or not they are in a city with a Strike Force by providing key data to fuel their investigations and prosecutions.
As we predicted in the days following the election, the Trump administration intends to keep the pressure on when it comes to detecting, and prosecuting, health care fraud. Constructing, implementing, and maintaining an effective compliance program is the surest means of staying off the feds radar.