HEALTH CARE FRAUD

Medical 2014BLOG - FRAUD - MEDICAL
by – Sheri de Grom

 

Compiling satisfactory evidence for prosecution of individual(s) committing health care fraud requires thousands of man hours and sheer determination that this time, this one isn’t going to get away. Often it takes years of full-time investigation on one case.

I thought you might be interested in how serious health care fraud must be before it will be considered for prosecution. The following actions occurred in June, 2014 and they represent a small fraction of current cases being worked.

The owners of Elizabethtown Hematology, PLC of Louisville, KY agreed to pay $3,739 to settle false billing to Medicare, Medicaid, Tricare and the Federal Employes Health Benefit Program.

Leonard Kibert, MD and four others of Houston, TX were charged in a 47-count indictment alleging a conspiracy to defraud Medicare of $2.9 million. A trial date is pending.

A Los Angeles physician was indicted for a $33 million scheme to defraud Medicare and one count of conspiracy to commit health care fraud. A trial date is pending.

Husband and wife owners of Ohio Ambulance Company were sentenced to prison and ordered to repay $800,000 to Medicaid for transportation services they didn’t actually provide.

Indictment of two Florida scientists for obtaining government research contracting by fraud. Additional charges included wire fraud, identity theft and falsification of records in a federal investigation. If convicted on all counts, each faces a maximum penalty of twenty years in federal prison. The United States is also seeking a money judgment in the amount of $10,000,000 which reflects the proceeds of the charged criminal conduct.

A Miami Beach osteopathic physician was sentenced to 70 months in prison followed by 3 years of supervised release as a result of a Medicare fraud scheme. In addition, the judge entered a $1.6 million forfeiture money judgment against the physician and ordered the forfeiture of his Miami Beach residence and a 2002 Mercedes Benz. The doctor is also to pay restitution to the Centers for Medicare and Medicaid Services.

The U.S. Department of Justice has ordered Omnicare, Inc., the nation’s largest nursing home pharmacy company to pay $124 million to settle allegations involving false billing to federal health care programs. Omnicare, Inc., has agreed to pay $124 million for allegedly offering improper financial incentives to skilled nursing facilities in return for their continued selection of Omnicare to supply drugs to elderly Medicare and Medicaid beneficiaries.

I could list page after page of medical fraud abuse convictions and indictments for June 2014. However, the purpose of this blog is to give you an idea of the size and frequency of fraudulent claims against Medicare and other health care insurance plans before prosecution will be considered.

I’ve seen thousands of cases wherein individual(s) are committing health care fraud on a daily basis, yet the dollars aren’t deemed high enough to qualify assigning a team of agents to investigate the activities in order to press federal charges.

Due diligence is required of every citizen to insure their insurance company is not being gouged by a medical provider and they are using your name in the process. Insurance fraud is the fastest growing criminal activity of white collar crime in the United States.

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About sheridegrom - From the literary and legislative trenches.

Retired Fed/JAG, 5 yrs. on Capitol Hill. Former book buyer for B&N. Health Care Reform proponent to include Tri Care and Medicare. Actively pursuing legislative change wherein dual retirees are exempt from enrolling in Medicare @ their own discretion without affecting other benefits. Active legislative analyst. Now writing womens' fiction and professional book reviews. Concerned citizen of military drawdown.
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73 Responses to HEALTH CARE FRAUD

  1. Emily Grace says:

    Hi Sheri!
    My inbox is singing with all your recent writings. I’m working on catching up. Just wanted to say hi today!
    :)
    Emily Grace

  2. tamizbu says:

    Reblogged this on Thingsufindthatareunfairandunjust and commented:
    Wow just wow, no wonder there isn’t enough funds to help the poor and lower middle class with free healthcare because the Healthcare crooks are taking it all! Certain major Dental Franchises needs to be added to the list of crooks also… I don’t know what this world is coming too, all that I can do is smh and pray.

  3. inesephoto says:

    Good grief, what a list! Crooked, as if they don’t earn enough! Greed, greed… Thank you for sharing this, Sheri. Hope you are well.

  4. kkessler833 says:

    Wow! I didn’t know there was so much medical fraud! This is awful!

    • Yes, medical fraud cost more than medical care provided when compared to the national index. Until we have a federal attorney general not controlled by lobbyist things will continue as they are. There’s a great deal of fraud committed by low level criminals but because it’s a federal offense, nothings done. Sometimes a private individual will notice something irregular on their own Explanation of Benefits and question it. If the provider’s billing office cannot provide an adequate answer, it’s at that point an individual needs to notify their insurance company of the possibility of fraud. It will keep your premiums from going up even if you are part of a large group plan or are privately insured through a small plan. We can no longer take for granted that everything is correct on our statements. Thanks for stopping by.

  5. Good heavens, Sheri … that list is frightening when you consider it’s not even the tip of the ice-berg. How frustrating it must be on an individual basis to face this horror.

    • Florence – What’s really frustrating is the presidential appointed Attorney General has the power to veto the prosecution of any case federal and state agents have spent hundreds and sometimes thousands of hours investigating not to mention the like amount of money. We’d go with case in hand, knowing it was ready for the court room and have our hard work tossed aside as if we’d been out in the field making mud pies. It was dangerous and exhausting work and then have someone push it aside because it didn’t fit party politics really got to us time and time again. And yes – the June examples don’t come close to that tip of the ice-berg in case number or billions of dollars stolen from tax dollars as well as commercial insurance companies. I can easily rant for months on this one issue. Let’s just say I’m mad as all get out and that’s me being polite!

  6. Reblogged this on By the Mighty Mumford and commented:
    CAN’T TRUST ANYBODY THESE DAYS!!!

    • Johathan: Thanks for the reblog. And, yep – when it comes to the federal government refusing to prosecute these cases, there-in lies the blame. The thieves are destroying our health care faster than anyone else and no one cares enough to do anything about it. We are being buried alive with presidential appointees who refuse to take action.

      • That’s what you get…from political wonks who care more for power and personal benefits than the people they supposedly serve. Then…any old stinky program will do. If folks are stupid enough to accept lies for answers—what of it (they seem to think)?

  7. This really is horrifying Sheri but as you suggest, the ordinary citizen doesn’t seem to have much comeback when these are the sums being prosecuted.

  8. Paulette, You are among the few to question charges on an EOB. It is something everyone should do. Many simply toss their EOBs into a drawer and never dig them out until tax time and then it’s too late to correct much of anything. I consider checking an EOB to checking my receipt when dining at a fine restaurant. I never automatically sign that particular check. Time and again I’ve found hidden charges and have asked about them. You’d be surprised how often the manager cannot explain what the charges are and he removes the ‘error’ as he calls it and offers a free dessert. I’m a diabetic and don’t want dessert. I’ve now taken my reply a step further. I reply, I don’t eat dessert and I’d much rather always receive an honest check along with the remainder of your guests. It’s funny how the manager more often than not doesn’t have a reply. Maybe the only thing he knows is to offer ‘dessert.’

  9. willowdot21 says:

    Another thought provoking post!

  10. All insurance fraud is terrible, particularly when you’re informed enough to realize it’s the people paying premiums who get screwed by frauds. However, the greatest fraud ever perpetrated dealing with healthcare is the Affordable Care Act – so-called Obamacare.

    • David – I couldn’t agree with you more in the fact that Obamacare is the greatest healthcare fraud this country has ever seen.
      Most of the healthcare fraud I investigated concerned Medicare and Medicaid and federal insurance plans but what always made me so mad is that after working hundreds and even thousands of hours and having an air-tight case, complete with legal citations ready to go to court, the Attorney General’s Office wouldn’t take them on. The cases simply weren’t big enough for him to make a name for himself in the political arena. Those of us that put in the endless hours, placed ourselves in harms way and on and on have never learned to overlook the fact that presidential appointees do not care about the American people. They are all in the position to further themselves and line their own pockets from the tragedies of the American taxpayer.
      By the way, I went to your Gavitar page several times to try to log into your blog but I couldn’t get in that way. I think possibly your Gavitar is not linked properly. I wasn’t linked until another blogger advised me of the situation.
      Have a great weekend. Sheri

  11. This defies reason! What a job you have accomplished.
    Where I live I’ve been told and others have repeated a similar statement. “You have insurance. They’ll pay for it.” This means the Plan gets charged at a higher rate because this or that person has insurance.
    Where there is money, there is ruthlessness.

    • Tess – Yes, there’s so much corruption everywhere. It is a tough issue to corral. Just as soon as you have a group of sophisticated criminals shut down, their family members have already set up someplace somewhere else. I did this type of work for so many years and you can readily see how soon it can be frustrating. My theory was the ‘little guy’ stealing personal medical information from ordinary citizens was just as guilty as the big cooperation’s stealing massive amounts of money. When we pay no attention to the criminals engaging in $5,000 or less in criminal activity, that simply allows them to go on and carry out larger crimes. I’ve missed you and want to get to your blog and see what all you’ve been up to lately. Sheri

      • Year by year we read about more and more white collar crime. Is nothing sacred anymore?

        Indeed, I can imagine what a frustrating job it must be tracing the crumbs (small crimes) to the brash bigger and biggest ones. It the little guy that end up paying for the wrongs of other, which I find heart-crushing.

        You are so sweet. I’m still here, Sheri. You’ve perked me up by being interested. I can’t keep up with the blogosphere and have little restriction on my time. How do you manage?

  12. Denise Hisey says:

    Sheri, this is a topic of epic proportions. Those on Medicare are by default more vulnerable to fraud because many of those patients are unable -for various reasons – to track and/or confront providers about their bills. (that’s separate from medical ID theft, but still a huge problem).

    A hand therapy clinic I did some consulting for was paid a pittance for certain services and had to provide piles of documentation for simple procedures that they even had hard copies of the PCP referrals for. Yet, millions of dollars are freely paid to non-existent providers and providers who are clearly being fraudulent. It doesn’t make sense.

    • Denise – In all the years I worked first at Jag and then later on as lead on an investigative team, I saw what you described time and time again. Patients are unable to get the care they need and crooks pad their accounts with millions of dollars. One of these days soon, I’ll post an actual investigation of the events that goes into preparing solid information to bring a criminal investigation down.

      By the way, thanks to your savvy advise, my therapist is now out of the Medicare loop hole and plans to contact BC/BS today. Yesterday she asked me if she could bill BC/BS directly and I told her I thought so since she has the letter for them to place on file that she’s opted out of Medicare. I’ll be posting a blog soon about what we’ve learned, thanks to you, about the Medicare System and mental health care. Thank you a million times over. Sheri

      • Denise Hisey says:

        Sheri,
        I’ll look forward to both posts you mention. You are a wealth of information!

        And I’m so glad to hear you’ve made progress with the Medicare situation. Your provider can bill BC/BS directly once that letter is on file with them. One word of caution -I am dealing with a BC/BS plan in Washington state that even though it’s on file, they deny every claim and I have to call and remind them Doc is opted out. Then they look in the file, agree, reprocess and pay. One way to avoid that is mail a copy of the opt out letter every time with a paper claim. Good teamwork here Sheri! Happy to have helped!

  13. Jane Sadek says:

    And what they are doing to Medicare they will do to Obamacare. The system is broken.

    • Hello, Jane. I’ve been thinking of you and that new house of yours. I hope to have a few days at home and get caught up with many blog entries, etc. When I haven’t been able to keep up properly, I get downright cranky!
      Remember those blogs you did sometime back and your thrill with shopping with your iPhone. Do you remember the links to those posts or perhaps I need to look into your archives.
      I’ve had some rough days with Tom’s emergency heart surgery and my nerve pain has advanced to the next level, but all in all, I’m plugging along. It’s always wonderful to see you here. Sheri

      • Jane Sadek says:

        Tom’s emergency heart surgery!! Girl, I don’t know how you do all you do!

        Fid Me (http://www.fidme.com/en) is how I store my loyalty cards on my phone. Shopkick (http://www.shopkick.com/) is the shopping rewards app. I’ve earned free gas, free meals and other rewards. When I shop at Target I use Cartwheel (http://cartwheel.target.com) to get online coupon deals and then a Target RED Card (http://www.target.com/redcard/main) to get 5% more off everything. There are zillions of coupon apps, but Ibotta (https://ibotta.com/) and Retail Me Not (http://www.retailmenot.com/) are the ones I have on my phone.

        I hope Tom’s surgery has been successful and that the caregiver gets a break!

        • Jane – Thank you for all the links. I’ve printed them out so I can refer to them when I’m waiting on doctor appointments and on and on. Thanks for sending them. I was prepared to chase back in your blogs because I was certain I would find them. I want to catch up with your life. I’ll be blogging about Tom’s emergency heart surgery in the near future. It was a success once I fired 4 doctors that almost killed him and found 4 more I like thus far.

          I’m not sure when the caregiver gets a BIG LUXURIOUS BREAK but I’ve hired a housekeeping service to clean from ceiling to floor and wall to wall. I can hardly wait other than I’ll have to pick up the clutter before they arrive. I’ve also hired someone to mow and weed-eat the lawn plus treat it and all that stuff so that’s going to be two big chore off me. I’ve really let the papers and stuff stack up while Tom’s been so sick this time and I know that adds to my stress. And, oh yes, the caregiver (that would be me) has lost 127 pounds and I must go through my closet and nothing fits – not even close. I’ve tossed out things from time to time but now even my shoes don’t fit. I knew you’d appreciate this last tid bit since you’ve been on the Atkins thing.

    • Jane – You are correct on this one. Obamacare needs to be reversed. Too many crooked fingers cannot stay out of the pie and no one is willing to do anything about it even when the evidence is put in front of them. Presidential appointees will not prosecute because that looks bad for Obama so in the meantime, everyone needs high quality health care and it’s not available for anyone.

  14. ksbeth says:

    this is absolutely horrendous and these companies play the odds, knowing the challenge ahead of those who find them, call them out and attempt to prosecute them. there is no excuse for this – it all stems from greed, and not caring about anyone other than oneself and preying on people, just trying to live a more healthy life, or ill, and unable to understand the invoices, or lacking the time to follow up and correct inconsistencies.

    • Beth – You captured the phrase, ‘attempt to prosecute them’ perfectly. I can’t begin to tell you how many crooks we had to release back into the world of crime simply because a US Attorney thought the case wasn’t worth pursuing. I know the US Attorneys are busy but I’d love for a special court to be set up for these thieves. They are causing our insurance pools to run dry.

  15. FlaHam says:

    Sheri, I applaud your work, and the work of the so many over worked investigators. I am one that consistently reviews what BCBS is being charged with by my doctors. When I get my EOB I compare it to my calendar and type of appointment. If I see something out of whack I go back to the doc’s office immediately, and call BCBS. To say I have pissed off the billing office of some of my doc’s is an understatement, because I do have the ability to piss folks off LOL ask my wife LOL. What I do, we should all do to some degree or another, but I understand that sometimes we are left at the mercy of crooked or incompetent billing offices. Or we don’t have the necessary skills to watch out for ourselves, which leaves at the mercy of the doctors’ office. This is an outstanding post, providing information we all need to heed. It also makes us aware of a real problem that could impact us on so many levels, especially in the continued raising of rates, coupled with reduction of services. Thanks, Bill

    • Bill, I had what I’m sure was a brilliant reply for you and then with my vast talent of technical inability – heaven only knows where I sent it. That was 2 or 3 days ago. I knew I wanted to have time to read your blogs when I returned and hopefully I’ll be able to do that now. It’s like going to the movies. I have my diet coke and my Simply Popcorn and we’re ready to see what you have to say this week.

      I’m so thankful you go over your EOBs. I’ve been reading a lot of new ‘guidelines’ about Hospice and pharmacy charges to go into effect Jan 2015. It seems to be just one more way Medicare is trying to stick it to their clients that have no choice other than Medicare. It comes under the Medicare Part D so it shouldn’t have anything to do with you. Hopefully.

  16. gpcox says:

    I knew it – I just knew it! Great investigations, Sheri.

    • G.P. – Thanks, G.P. Some of the schemes are so elaborate they are more difficult than going to work everyday. You knock one down and another 3 pop up. I don’t like looking at life that way, but when you are in the midst of working an investigation, it certainly seems there’s no place to turn wherein you’ll find good hardworking people. Sheri

  17. Being sick is stressful enough but to be forced into being the only advocate you have is especially unfortunate.

    • PLGC: Oh, dear. I hope you haven’t been ill. It’s not surprising to me that sometimes people simply give up on what’s facing them. The big cases I mentioned in this blog have all been investigated by senior level investigators and the data put together so that they can be prosecuted. However, the cases listed are for just a handful of what really happened during the month of June.

  18. There are always going to be people who will take advantage of others, especially if it’s for money. I’ve seen several programs on t.v. regarding the elderly being taken advantage of by younger people who steal their life saving and the like. It’s really so sad.

    • Patti – Unfortunately we will always have criminals and it’s sad that some of them will never be punished and others will suffer because of what’s been done to them. We as a society cannot afford to turn away and allow this behavior to continue. Each time we know fraud is being committed, it is our duty to report it no matter how small the amount.

      More often than not, when it’s the type we hear of in the news, etc. it’s when family members are either emotionally, physically or economically abusing their elders and to me, that’s the worst of all.

  19. huntmode says:

    Sheri, a very good, valuable post. The costs of litigation, much less investigation, are extraordinary and those same insurance companies will pay off, rather than prosecute, lawsuits that have no standing just because it is cost prohibitive to prosecute.

    • Huntie: That’s the very essence of the problem. We’d spend thousands of dollars building an air-tight case and then the attorney general would say it wasn’t worth their investment in time, money, and so on. Because it’s a federal crime, the cases couldn’t be tried in state courts although often the money lost belonged to a specific state of insurance company operating within a specific state. I thought it was important to post to let others the federal government did indeed make an effort to put some meat in the business of bringing criminals to justice. However, once we reached the presidential appointee tier you could forget it – nothing happened anywhere.

  20. Gallivanta says:

    The cost of fraud is staggering but what keeps coming to my mind is “why”. Why do people feel the need to do this? Or why do they believe they are entitled to commit fraud? Why do societies produce people so lacking in conscience?

    • Gallivanta, These are the individuals with the faulty thinking that come under the criminal evil component. They are the ones buying guns at gun shows wherein records are to be checked before they can buy but we know how that doesn’t work. These individuals aren’t mentally ill. They are the evil that reside in our society and somehow have gotten the message that the world owes them a living. Many have grown up in multiple generations of crime families. They know of no other form of work.

  21. That is absolutely HORRIFIC! Thanks fur calling attention to this purroblem….I guess some humans furget to take their brains with them when they go to work! *(morons)*

  22. A serious problem you address, Sheri, with great courage and honesty. Brava!

  23. M-R says:

    Dowunder, we have certain ethnic groups known for health fraud – insurance for damages post car accident, etc., Sheri. Can you imagine that such a situation arises? – what the devil is going on with the administration of the funds when such situations can emerge ! Isn’t there any kind of cross-checking by computer ?
    I know, I’m railing. Sorry.
    I like your post VERY MUCH.

    • Margaret-Rose: Please, go on and on about the injustice of it all for that is exactly what it is. I know of the post car accident damages and how they suck insurance policies clean and then turn to any other pocket that might be available. I believe auto insurance companies are ahead of health insurance companies when it comes to finding individuals who abuse the system over and over. Yet, the shame of it all is the doctors, and I use that term loosely, working with the patient pads the medical bills so much, it turns into an astronomical payment of insurance funds. often the ‘doctor’ will have an ‘attorney’ working with him and they stretch the medical treatment out as far as possible and by that time, the insurance company doesn’t want to go to court and they simply write the check for pain and suffering, lost wages, medical costs, and on and on. It’s a real racket in the US.

      I worked this very type of investigation for my first two years at JAG in California. It seemed every military recruiter car we had on the road, ten other vehicles made it their number 1 priority to run into the recruiter’s vehicle.

      • M-R says:

        I sit here trying to imagine how the world would be without people like that … and failing to come up with a mental image.

  24. Lignum Draco says:

    Fraud is fraud. No matter who by, or the amount involved. A shame that it must involve a certain dollar amount before it is cost effective to prosecute.

    • Lignum – You are so right. I believe one of the reasons I love your photography so much is that it’s real. The expressions you capture aren’t made up. They bring up glorious emotions and can be interpreted from so many different points of view. There’s no doubt what that woman in front of the chocolate store wants to do (yet each of us are allowed to form our own opinion).

      I agree with you completely about our US Attorney general believing health frauds must be a certain dollar amount before they’ll be considered for prosecution. I’ve always considered it much smarter to go to trial with low level criminals and sentence them before they turn into master minds of larger cases.

      I always appreciate your comments.

  25. Pathetic. I shutter to think of how many are being missed. I know when my mother was alive and toward the end that her doctor was billing medicare for procedures she hasn’t had. We know that for a fact. We called it to his attention and things were removed from her bill but how many others never called him on it. That and the above cases are a tiny number of what must be happening. The worst part of it all is the poor patients end up paying one way or another for this deceit. Another powerful important post. Thank you.

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