On September 30, 2020, a multi-departmental announcement was made of the largest health care fraud and opioid takedown in the United States, involving 345 defendants responsible for more than $6 billion in alleged fraud losses.

Acting Assistant Attorney General Brian C. Rabbitt of the Justice Department’s (DOJ) Criminal Division, Assistant Director Calvin Shivers of the FBI’s Criminal Investigative Division, Deputy Inspector General Gary Cantrell of the Department of Health and Human Services Office of Inspector General (HHS-OIG) and Assistant Administrator Tim McDermott of the Drug Enforcement Administration (DEA) collectively announced a historic nationwide enforcement action involving 345 charged defendants across 51 federal districts, including more than 100 doctors, nurses and other licensed medical professionals.

The defendants were charged with submitting more than $6 billion in false and fraudulent claims to federal health care programs and private insurers – including more than $4.5 billion connected to telehealth and more than $845 million connected to substance abuse treatment facilities.

Telemedicine Cases

The highest proportion of alleged fraud loss related to schemes involving telemedicine – $4.5 billion in allegedly false and fraudulent claims submitted by more than 86 criminal defendants in 19 judicial districts. According to the United States, certain telemedicine executives allegedly paid doctors and nurse practitioners to order unnecessary durable medical equipment (DME), genetic and other diagnostic testing, and pain medications, either without any patient interaction or with minimal telephone conversations with patients they had never personally met or seen. The DME companies, genetic testing laboratories, and pharmacies then purchased the orders in exchange for kickbacks and bribes and submitted false and fraudulent claims to Medicare and other government insurers.

In addition to the criminal charges, the Centers for Medicare and Medicaid Services (CMS) Center for Program Integrity separately announced that it has taken a record-breaking number of administrative actions related to telemedicine fraud, resulting in the revocation of Medicare billing privileges of 256 additional medical professionals for their involvement in telemedicine schemes.

The “sober homes” cases include charges against more than a dozen defendants in connection with more than $845 million of allegedly false and fraudulent claims for tests and treatments for vulnerable patients seeking treatment for drug and/or alcohol addiction. Defendants include physicians, owners and operators of substance abuse treatment facilities, and patient recruiters (referred to in the industry as “body brokers”).

These individuals are alleged to have participated in schemes involving the payment of illegal kickbacks and bribes for the referral of patients to substance abuse treatment facilities who were then subjected to medically unnecessary drug testing and therapy sessions that were frequently not provided, which resulted in millions of dollars of false and fraudulent claims being submitted to private insurers. Medical professionals also allegedly prescribed medically unnecessary medications, including controlled substances, to these patients, sometimes in an effort to entice them to stay at the facility. Unbelievably, patients were often discharged only to be admitted to other treatment facilities, or referred to other laboratories and clinics, in exchange for more kickbacks.

Opioid Cases

The cases involving the illegal prescription and/or distribution of opioids include charges – and some guilty pleas – involved more than 240 defendants who allegedly participated in schemes to submit more than $800 million in false and fraudulent claims to Medicare, Medicaid, TRICARE, and private insurance companies for treatments that were medically unnecessary and often never provided. According to the government, in many cases, patient recruiters, beneficiaries and other co-conspirators were allegedly paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare. These cases also involve charges against medical professionals involved in the distribution of more than 30 million doses of opioids and other prescription narcotics.

Conclusion

In addition to the charges announced above, the DOJ announced the creation of the National Rapid Response Strike Force of the Health Care Fraud Unit of the Criminal Division’s Fraud Section. This new Strike Force’s mission is to investigate and prosecute fraud cases involving major healthcare providers that operate in multiple jurisdictions.

Interestingly, the Strike Force led the telemedicine initiative and helped lead the sober homes cases included above.

Health

Source: Largest Health Care Fraud and Opioid Takedown Announced by Department of Justice