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DOJ's Rebecca Pyne on fighting fraud by organized crime


Health insurance programs have lost hundreds of millions of dollars due to fraud by organized crime rings. To learn how payers can recognize and respond effectively to this threat, FierceHealthPayer: Anti-Fraud spoke to Rebecca Kettelle Pyne, a trial attorney in the organized crime and gang section of the criminal division of the U.S. Department of Justice.

FierceHealthPayer: Anti-Fraud: Why are organized crime syndicates and gangs turning to health insurance fraud, and is this type of criminal behavior the work of American syndicates, international ones or both?

Rebecca Pyne: "Organized crime" is a phrase that can be interpreted in many ways. Our office is interested in international organized crime and traditional mafia/La Cosa Nostra (LCN) organized crime activity. So our office has a more limited focus in the world of healthcare rather than broadly [examining] any organized activity.

There are a number of reasons why organized crime groups would find it attractive to be involved in healthcare fraud. They're simply following the money, since successful fraudulent billing schemes can generate millions of dollars in a relatively short period. Healthcare fraud is also attractive because once a fraud scheme is perfected, it can be duplicated locally, regionally and even nationwide. This multiplies the profits from a particular scheme.

Also, there may be a belief that there's a low risk of detection in healthcare fraud. At least when the analysis is done between risk and reward, the analysis may weigh in terms of the reward side. Sophisticated schemes can be layered so that those who mastermind them are removed from actual criminal conduct. They can direct the scheme and profit from it but insulate themselves from directly engaging in the front-line criminal act.

In the past, there was also a perception that punishments for healthcare fraud may be less severe than other crimes, but I think that's no longer true. Federal statutes and the sentencing guidelines have enhanced enforcement and also increased sentences for healthcare fraud.