In addition to the financial costs of healthcare fraud and abuse, there are also other considerable impacts experienced by fraud and abuse victims. There is a critical interrelationship between healthcare fraud and health disparities, as vulnerable and medically underserved beneficiaries are routinely targeted, and often receive substandard, medically unnecessary, and even harmful care.
Consequently, healthcare fraud and abuse can be easily overlooked health determinants that contribute to or perpetuate existing health disparities.
In addition to case studies of healthcare abuse and fraud that targets medically underserved and vulnerable individuals, the technical paper covers detection, response, and mitigation efforts undertaken to stymie this abusive behavior and its impact. Finally, the paper outlines a call to action through seven recommendations that should be considered to mitigate the impact of healthcare fraud and abuse on people who disproportionately experience health disparities.
MITRE is proud to be an equal opportunity employer. William J. John S. Chamber of Commerce Report. Ibid, p. Mercy Health Plans, Fraud Hotline, Harman, Laurinda. Ethical Challenges in the Management of Health Information. Rudman, W. Garvin, J. Watzlaf, and S. Geis, G. Jesilow, H. Pontell, and M. Morrison, James, and Theodore Morrison. Klein, Roger D. McCall, Nelda, Harriet L. Komisar, Andrew Petersons, and Stanley Moore. Iglehart, John K. Kalb, Paul E. Wynia, Matthew K. Cummins, Jonathan B.
VanGeest, et al. Murkofsky, Rachel L. Phillips, Ellen P. McCarthy, Roger B. Davis, and Mary Beth Hamel. Grogan, Colleen M. Feldman, John A. Nyman, and Janet Shapiro. The Experience of Medicare Carriers. Jacobson, Peter D. Fraud Survey Pontell, H. Jesilow, and G.
Blanchard, T. Louis University Law Journal 43 : Pies, H. Lee, B. Davies, S. Smith, Russell G. Bloche, M. Pitches, D. Burls, and A. Gosfield, A. Sparrow, M. Boulder, CO: Westview Press, Michael, J. Morrison, James, and Peter Wickersham. Faddick, C. Kassirer, Jerome P. Brett, Allan S. Phillips, C. Shane, R. Malatestinic, W. Braun, J. Jorgenson, and J. Hand, R. King, M. Sharp, and M. Chute, C. Gruber, N. Shepherd, and R. Civil attorneys in the USAOs are responsible for bringing affirmative civil cases to recover funds that Federal health care programs have paid as a result of fraud, waste, and abuse, with support in those cases designated by the Civil Division for joint handling.
USAOs also handle most criminal and civil appeals at the Federal appellate level. In , the USAOs received 1, new criminal matters involving 1, defendants, and had 1, health care fraud criminal matters pending, 4 involving 2, defendants. The USAOs filed criminal charges in cases involving defendants, and obtained Federal health care related convictions. The USAOs use affirmative civil enforcement litigation to recover monies wrongfully taken from the Medicare Trust Fund and other taxpayer-funded health care systems, and to ensure that the Federal health care programs are fully compensated for the losses and damages resulting from such thefts.
The FCA subjects those who knowingly present false claims for payment to the government, including health care providers who submit claims to Federal health care programs, to treble damages and civil penalties. USAOs receive civil health care fraud referrals from a variety of sources, including from the Federal investigative agencies that refer criminal cases, and by means of qui tam complaints.
USAOs routinely assign civil AUSAs to every qui tam case filed in their districts, as well as all matters referred by a law enforcement agency. In , the USAOs opened new civil health care fraud matters including qui tam actions and matters referred by agencies and had 1, civil health care fraud matters and cases pending.
In order to maximize resources, Civil Division attorneys may become actively involved and participate with the USAOs in those qui tam cases that involve more than one district and potential recoveries substantially over one million dollars. In , USAOs filed or intervened in civil health care fraud cases.
In FY , the Division opened or filed a total of health care fraud cases or matters. In addition to these new efforts, the Division pursued existing cases or matters that remained open at the end of FY Division attorneys were actively involved in the recoveries described in the consolidated case recovery overview.
In addition, the Division provided in-depth, multi-day, training to AUSAs nationwide on the FCA, including issues relating to the investigation and litigation of qui tam cases, and continued to provide training to DOJ and HHS components on a regular basis.
Civil Division attorneys litigate a wide range of health care fraud matters, including cases involving allegations of overcharging by hospitals, and other Medicare Part A institutional providers; similar claims against suppliers of DME and other supplies under Part B of Medicare; claims that doctors and others have been paid kickbacks or other remuneration to induce referrals of Medicare or Medicaid patients, in violation of the Anti-Kickback Act and Stark laws; claims of overpricing and illegal marketing of pharmaceuticals by drug companies and related entities; and allegations that nursing homes have failed to provide necessary care to the elderly.
Among these are multi-district cases involving large health providers and suppliers that typically require coordination among affected Federal agencies, USAOs, state Medicaid Fraud Control Units and other state agencies, and various investigative organizations. The Civil Division continues to staff and provide a critical coordination function in the FCA investigations alleging pharmaceutical pricing fraud against government health care programs. These matters involve hundreds of manufacturers and related entities, span multiple districts and present myriad legal and factual issues.
In addition, close communication with state Medicaid Fraud Control Units and Attorneys General is ongoing to ensure that federal and state investigations and litigation are coordinated. Through this initiative, DOJ also makes grants to promote prevention, detection, intervention, investigation, and prosecution of elder abuse and neglect, and to improve the scarce forensic knowledge in the field.
Also, the Civil Division continues to co-chair, with the Criminal Division, the National Level Health Care Fraud Working Group to coordinate the health care fraud enforcement activities of all concerned federal and state agencies. The Fraud Section of the Criminal Division develops and implements white collar crime policy and provides support for the Federal white collar enforcement community.
The Fraud Section supports the USAOs with legal and investigative guidance and, in certain instances, provides trial attorneys to prosecute criminal fraud cases. For several years, a major focus of the Fraud Section has been to investigate and prosecute fraud in Federal health care programs.
The Fraud Section has responsibility for handling and coordinating complex health care fraud litigation nationwide. Intelligence After Next Modeling and Simulation National Security 8. Public Health Risk Management Publication Search.
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