"In some districts they don’t like to arrest white collar defendants. . . . We arrest everybody. Everybody gets arrested. No one walks." That was one comment heard from enforcement agents on Thursday, January 28, 2010, as the U.S. Departments of Justice (DOJ) and Health and Human Services (HHS) brought together law enforcement, private and public sector leaders and healthcare experts for the "National Summit on Health Care Fraud," the first national gathering of this kind and an initiative of the Health Care Fraud Prevention & Enforcement Action Team (HEAT).
HHS Secretary, Kathleen Sebelius, reiterated the Obama administration’s "zero tolerance" policy for fraud and alluded to a "historic" budget allocation for anti-fraud efforts that she anticipates will result in billions in savings. The summit focused on a two-pronged strategy of prosecution and prevention to help curtail the estimated $60 billion lost in public and private sectors yearly due to healthcare fraud.
In 2009, the DOJ charged more than 800 healthcare fraud defendants and obtained more than 580 convictions. On the civil enforcement side, the DOJ recovered $2.2 billion under False Claims Act (FCA) cases. Attorney General Eric Holder attributed much of this success to Medicare Fraud Strike Force teams, consisting of federal prosecutors, FBI agents and agents from HHS’s Office of Inspector General (OIG). Strike Force teams, described as the "core" of HEAT’s law enforcement mission, were introduced to Miami in 2007 and have since expanded to Los Angeles, Detroit, Houston, Brooklyn, Baton Rouge and Tampa Bay.
The Attorney General outlined a roadmap for the ongoing fight against fraud: a reinforced effort on strengthening HEAT, an expansion of Medicare Fraud Strike Forces to other geographic areas, budgetary investments to properly fight fraud, regulatory reform in order to prevent and deter fraud and the continued inclusion of the private sector in anti-fraud efforts.
Workgroups met in the afternoon in closed breakout sessions to discuss the use of technology to prevent and detect healthcare fraud; the role of states in preventing healthcare fraud; the development of effective prevention policies and methods for insurers, providers and beneficiaries; effective law enforcement strategies; and measuring healthcare fraud, assessing recoveries and determining resource needs. Summaries of the workgroup discussions will be made publicly available in a report. Also, enforcement agents suggested that HEAT is moving toward arresting individuals more quickly in order to curtail any ongoing suspected fraud, even if the case still is being investigated. One speaker noted that "Everything moves faster. . . . The times have changed. . . . We target everybody that the data indicates is an offender. We charge them quickly . . . ." The speaker further commented that "Some [agents] can’t wait for that [obtaining a complaint]. . . . They go to investigate the guy. They call the prosecutor up. They’re arrested on the spot. We’ll do the complaint later. All of that is legal." While the benefits of curtailing ongoing fraud as quickly as possible are obvious, such prosecution strategies carry a risk that innocent providers and suppliers working to comply in a heavily regulated area could arguably be cast by federal authorities as guilty until proven innocent.
Federal law enforcement officials could not be clearer that providers and suppliers should prepare for increased scrutiny and enforcement in the coming year. In the fervor to catch the wrongdoers, honest providers may find themselves swept up in the wide net that the HEAT efforts cast. Physicians, hospitals and other providers should continue efforts to meticulously document their compliance efforts, especially with regard to medical necessity.