Meeting the challenge of healthcare fraud, and what that makes of us


This is a reflection on some of the problems we face as fraud fighters and who we may become as a result of efforts to solve them.

I learned early on that we'll never completely eliminate healthcare fraud. We can make fraud harder to commit. We can try to predict program vulnerabilities and find fraud earlier to minimize loss. And we can heap crushing consequences on perpetrators to make healthcare fraud less attractive to would-be criminals.

But there will always be those who see health insurance as an overstuffed wallet someone dropped in the street. Big money, they rationalize, is there for the taking.

Fraud is a problem of tremendous range because it's committed by people with different abilities, resources and scruples.

At one end of the spectrum, there are convicted and accused criminals who run flawed schemes. Think of the freshman-class crooks who write personal checks to pay kickbacks and bribes. And in New York this week, three pharmacies, their owners and employees were indicted for cheating Medicaid out of $5 million. Red flags went up after audits revealed that quantities of drugs the pharmacies ordered from suppliers were less than those for which they claimed payment. Oops.

But then there are sophisticated, tough-to-unravel scams carried out by international organized crime groups. One of the largest Medicare fraud schemes ever perpetrated by a single enterprise was conducted by a crime ring with members in the United States and Armenia. That scheme operated shell clinics nationwide and drove more than $100 million in bogus bills to Medicare, as U.S. Department of Justice Trial Attorney Rebecca Pyne told FierceHealthPayer: AntiFraud in an exclusive interview.

Moreover, there are chilling cases that threaten not only finances but patient safety. In Michigan this week, neurosurgeon Aria O. Sabit, M.D., was arrested for his role in a scheme involving improper performance of lumbar spinal fusions, the FBI announced. This surgery usually involves placing a medical device in the spinal column; but Sabin apparently operated without doing that. He claimed payment for surgeries and led patients to believe he operated correctly on them, the announcement noted. But when the patients' back pain continued after surgery, many sought confirmatory consultations and learned nothing was implanted in them.

Fraud fighting is full of daunting challenges, but meeting them can develop heightened capacities in us. There are examples of investigative excellence in the field, of teamwork in unexpected places and pit bull tenacity leading to huge recoveries. And there's a level of leadership that's been called "nothing short of amazing."

Last week in Dallas, the National Health Care Anti-Fraud Association presented its investigation of the year award to a team of federal agencies for coordinated work on the case of United States of America v. Johnson & Johnson/Janssen Pharmaceuticals. This multiyear investigation alleged misbranding, off-label marketing and kickbacks relating to three prescription drugs. The case resulted in more than $2.2 billion in recoveries and was the third largest healthcare fraud settlement in American history.

The NHCAA also presented its 2014 medical director award to Aetna's Gordon Grundy, M.D., M.B.A., for significant contributions to program integrity including policy formation, clinical investigative guidance, and participation in SIU savings and recovery efforts.  

"As a direct result of his work, we have effectively stopped millions of fraudulent dollars from leaving Aetna and brought hundreds of cases to successful conclusion," Aetna SIU Senior Director Ralph Carpenter said of his colleague.    

While we won't see the end of healthcare fraud and probably haven't seen the worst of it, let's not forget what we can become as a result of fighting this crime with integrity. The good rises in and through us. That's something to appreciate as Thanksgiving nears. - Jane (@HealthPayer)

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DOJ's Rebecca Pyne on fighting fraud by organized crime
Mobsters find easy money in health insurance
The cautionary tale of Florence Bikundi, an excluded provider
NHCAA survey results provide a benchmark for SIUs
A tribute to good medical directors and veterans
Why it pays to watch for shell schemes