Health Care Fraud, Record $4.2 Billion Recovered In 2012,

Health and Human Services and the Department of Justice say that a record-breaking $4.2 billion were recovered as a result of joint efforts to address health care fraud in 2012.

Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder issued a report which showed that for every dollar the US government spent on health care-related fraud and abuse investigations over the last 36 months, it got $7.90 back. This is a record over a three-year period since the HCFAC (Health Care Fraud and Abuse) Program began sixteen years ago.

Is this huge haul a sign of better coordination among public authorities, or does it reflect an increase in criminality? The Justice Department and HHS believe it is a sign of the government's health care fraud prevention and enforcement efforts. $4.2 billion (2012) is an increase from $4.1 billion in 2011.

The money was recovered from companies and individuals who had tried to defraud federal health programs aimed at seniors and taxpayers for payments they were not entitled to receive.$14.9 billion have been recovered over the last four years, compared to $6.7 billion during the previous four-year period. Over $23 billion have been returned to the MedicareTrust Funds since 1997 by the HCFAC Program.

According to the Office of the Inspector General, US Department of Health & Human Services, during the fiscal year 2012:

• The Federal government won/negotiated more than $3.0 billion in health care fraud judgments and settlements, and it attained additional administrative impositions in health care fraud cases and proceedings.


• About $4.2 billion were deposited with the Department of the Treasury and the Centers for Medicare & Medicaid Services, transferred to other Federal agencies administering health care programs, or paid to private persons during the fiscal year.


• Of the $4.2 billion, the Medicare Trust Funds received transfers of approximately $2.4 billion during this period, and over $835.7 million in Federal Medicaid money was similarly transferred separately to the Treasury as a result of these efforts.

• The HCFAC account has returned over $23.0 billion to the Medicare Trust Funds since the program started in 1997.

According to HHS, "These findings, released today in the annual HCFAC Program report, are a result of President Obama making the elimination of fraud, waste and abuse, particularly in health care, a top priority for the administration."

HEAT (Health Care Fraud Prevention and Enforcement Action Team) was created in 2009 to fight fraud, abuse and waste in the Medicaid and Medicare programs, and to close in on people and entities which abuse the system and cost the American taxpayers billions of dollars.

Attorney General, Eric Holder, said:

Source found here

Kentucky: Pain Clinic Owners and Doctors Charged in Prescription Drug Conspiracies

August 17, 2012; U.S. Attorney; Eastern District of Kentucky

Local and Out of State Pain Clinic Owners and Doctors Charged in Prescription Drug Conspiracies 
PIKEVILLE-Between today and late Thursday afternoon, five indictments have been unsealed charging 22 defendants, including five pain clinic owners and six doctors, with offenses related to prescription drugs, money laundering, and health care fraud.

Former Owner of Daytona Beach Clinic Pleads Guilty To Fraud, Conspiracy, and Money Laundering

August 28, 2012; U.S. Attorney; Middle District of Florida

Former Owner of Daytona Beach Clinic Pleads Guilty To Fraud, Conspiracy, and Money Laundering 
Orlando, FL - United States Attorney Robert E. O'Neill announces that Joseph Wagner (62, Daytona Beach) today pleaded guilty to health care fraud, conspiracy to illegally distribute prescription drugs, and money laundering. Wagner faces a maximum penalty of 30 years in federal prison. He was indicted on June 13, 2012.

More Information on Ownership and Entity Status of Alabama Compounding Pharmacies Searched by FBI

Shoalanda Speaks blog is reporting more information this morning regarding the ownership and entity status of the compounding pharmacies raided in Alabama.  That article can be found here  and is quoted below:

Initial reports from the FBI on Wednesday identified one of two raided Franklin County pharmacies as Franklin County Pharmacy. Within two hours, the press release had been changed to Franklin Health-Mart Pharmacy. Today a spokesman from Franklin Pharmacy has addressed charges of insurance fraud; we now infer this to be the correct name of the third business raided.

Timothy A. Aaron, owner of Franklin Pharmacy, has previously worked at Sheffield Pharmacy (one of the other two raided) and the Drug Shop in Russellville. He's now listed as licensed in Franklin County only. According to their ads, the pharmacy specializes in a product dubbed Optimal Pain Control, or OPC. Established in 2010, the business operates from a steel frame building just off Hwy. 43 north of downtown Russellville.

The drug store is listed as an LLC; however, it appears to be operating under an umbrella corporation. The pharmacy's principal income is produced via sales of OPC. One source reported to us that its gross receipts from this pain formula last year were 250K. A few other sources that we could not verify have placed the figure much, much higher. Apparently the majority of this revenue is generated through online sales.

One reader reported Russellville Pharmacy still closed this morning, while a second reported it was open at some point. Hopefully any problems with accounting won't affect the day to day operation of these businesses. Employees, including associate pharmacists, have no control over the business practices of their employers. There are reportedly over 300 employees of these three pharmacies, all we assume doing the jobs for which they were hired. Let's remember that.

Health Care Fraud 101

FDA 101: Health Fraud Awareness

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On this page:

• Common Types of Health Fraud
• Don't Be a Victim
• Report Problems

Health fraud is the deceptive sale or advertising of products that claim to be effective against medical conditions or otherwise beneficial to health, but which have not been proven safe and effective for those purposes.

In addition to wasting billions of consumers' dollars each year, health scams can lead patients to delay proper treatment and cause serious—and even fatal—injuries.

Since the 1990s, peddlers of fraudulent "health" products have used the Internet as a primary tool to hawk their wares. This has kept the U.S. Food and Drug Administration (FDA) and other agencies busier than ever in protecting the public from health fraud.

Since June 2008, FDA has warned consumers not to use bogus cancer-treatment products marketed online by 28 U.S. companies. These products include tablets, teas, tonics, salves, and creams sold under more than 180 different brand names.

And since December 2008, FDA has warned about more than 70 weight loss products containing unapproved pharmaceutical ingredients and chemicals not listed on the labels. Some of these ingredients present serious health risks when taken in dosages recommended on the product label.

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Common Types of Health Fraud

Cancer fraud: Among the many long-running cancer scams is the Hoxsey Cancer Treatment, an herbal regimen that has no proven benefit. Another scam involves products called black salves. These are offered with the false promise of drawing cancer out from the skin, but they are potentially corrosive to tissues.

Cancer requires individualized treatment by a specialized physician. No single device, remedy, or treatment can treat all types of cancer.

Patients looking to try an experimental cancer treatment should enroll in a legitimate clinical study. For more information, visit the National Cancer Institute Clinical Trials Web site.

HIV/AIDS fraud: There are legitimate treatments that can help people with the human immunodeficiency virus (HIV). While early treatment of HIV can delay progression to AIDS, there is currently no cure for the disease.

Relying on unproven products and treatments can be dangerous and cause delays in seeking legitimate medical treatments that have been proven in clinical trials to improve quality of life.

Safe, reliable testing to determine whether you have HIV can be done by a medical professional.

To date, there is one FDA-approved testing system that allows individuals to test themselves at home. It is an HIV collection system that tests only for HIV-1, which is the cause of the majority of the world's HIV infections.

The test, sold either as The Home Access HIV-1 Test System or The Home Access Express HIV-1 Test System, allows blood samples to be sent to a laboratory for testing with an FDA approved HIV-1 test.

Arthritis fraud: The U.S. Federal Trade Commission says consumers spend about $2 billion annually on unproven arthritis remedies that are not backed by adequate science.

For current, accurate information on arthritis treatments and alternative therapies, visit the Arthritis Foundation Web site.

Fraudulent "diagnostic" tests: Doctors often use in vitro diagnostic (IVD) tests—in tandem with a physical examination and a medical history—to get a picture of a patient's overall health.

These tests involve blood, urine, or other specimen samples taken from the body. They help diagnose or measure many conditions, including pregnancy, hepatitis, fertility, HIV, cholesterol, and blood sugar.

It's rare that the use of only one of these tests can provide a meaningful diagnosis. You can buy IVD tests in stores, through the mail, or online. Many of these tests are regulated by FDA and sold legally. However, many others are marketed illegally and do not meet FDA's regulatory requirements. These tests may not work or may be harmful.

To find out whether FDA has cleared or approved an IVD test for a particular purpose, call FDA at (888) 463-6332, or your local FDA district office.

Bogus dietary supplements: The array of dietary supplements—including vitamins and minerals, amino acids, enzymes, herbs, animal extracts and others—has grown tremendously.

Although the benefits of some of these have been documented, the advantages of others are unproven. For example, claims that a supplement allows you to eat all you want and lose weight effortlessly are false.

Claims to treat diseases cause products to be considered drugs. Firms wanting to make such claims legally must follow FDA's premarket New Drug Approval process to show that the products are safe and effective.

Weight loss fraud: Since 2003, FDA has worked with national and international partners to take hundreds of compliance actions against companies pushing bogus and misleading weight loss schemes.

FDA has recently enhanced efforts to stop sales and importation of—and to warn consumers about—weight loss products that contain dangerous prescription drug ingredients that are not listed on the label.

Sexual enhancement product fraud: FDA has warned consumers about numerous illegal drugs promoted and sold online for treating erectile dysfunction and for enhancing sexual performance.

Although they are marketed as "dietary supplements," these products are really illegal drugs that contain potentially harmful ingredients that are not listed on the label.

Diabetes fraud: FDA has taken numerous compliance actions against sales of fraudulent diabetes "treatments" promoted with bogus claims such as

• "drop your blood sugar 50 points in 30 days"
• "eliminate insulin resistance"
• "prevent the development of type 2 diabetes"
• "reduce or eliminate the need for diabetes drugs or insulin"

Influenza (flu) scams: Federal agencies have come across contaminated, counterfeit, and subpotent influenza products.

FDA, with U.S. Customs and Border Protection, has intercepted products claimed to be generic versions of the influenza drug Tamiflu, but which actually contained vitamin C and other substances not shown to be effective in treating or preventing influenza.

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Don't Be a Victim

It's ultimately up to the buyer to beware of potential health fraud. Know of the potential for health fraud and learn about the common techniques and gimmicks that fraudulent marketers use to gain your attention and trust.

For instance, testimonials from people who say they have used the product may sound convincing, but these can easily be made up. These "testimonials" are not a substitute for scientific proof.

Also, never diagnose or treat yourself with questionable products. Always check with your health care professional before using new medical products.

Be wary of these red flags:

• claims that a product is a quick, effective cure-all or a diagnostic tool for a wide variety of ailments
• suggestions that a product can treat or cure diseases
• promotions using words such as "scientific breakthrough," "miraculous cure," "secret ingredient," and "ancient remedy"
• text with impressive-sounding terms such as: "hunger stimulation point" and "thermogenesis" for a weight loss product
• undocumented case histories by consumers or doctors claiming amazing results
• limited availability and advance payment requirements
• promises of no-risk, money-back guarantees
• promises of an "easy" fix
• claims that the product is "natural" or "non-toxic" (which doesn't necessarily mean safe)

Don't be fooled by professional-looking Web sites. Avoid Web sites that fail to list the company's name, physical address, phone number, or other contact information. For more tips for online buying, visit Buying  Medicines and Medical Products Online.

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Report Problems

If you find a person or company that you think is illegally selling human drugs, animal drugs, medical devices, biological products, foods, dietary supplements, or cosmetics, report it to FDA.

To report problems with FDA-regulated products, call your local FDA Consumer Complaint Coordinator.

To report unlawful sales of medical products on the Internet, visit Reporting Unlawful Sales on Internet.

This article appears on FDA's Consumer Updates page, which features the latest on all FDA-regulated products.

Date Posted: May 12, 2009

Page Last Updated: 12/08/2011 

From the FDA website found here.

Ground-Breaking Public-Private Partnership to Prevent Health Care Fraud

News Release

FOR IMMEDIATE RELEASE July 26, 2012

Contact: HHS Press Office (202) 690-6343

Obama administration announces ground-breaking public-private partnership to prevent health care fraud

Washington - Health and Human Services (HHS) Secretary Kathleen Sebelius and Attorney General Eric Holder today announced the launch of a ground-breaking partnership among the federal government, State officials, several leading private health insurance organizations, and other health care anti-fraud groups to prevent health care fraud. This voluntary, collaborative arrangement uniting public and private organizations is the next step in the Obama administration’s efforts to combat health care fraud and safeguard health care dollars to better protect taxpayers and consumers.

The new partnership is designed to share information and best practices in order to improve detection and prevent payment of fraudulent health care billings. Its goal is to reveal and halt scams that cut across a number of public and private payers. The partnership will enable those on the front lines of industry anti-fraud efforts to share their insights more easily with investigators, prosecutors, policymakers and other stakeholders.  It will help law enforcement officials to more effectively identify and prevent suspicious activities, better protect patients’ confidential information and use the full range of tools and authorities provided by the Affordable Care Act and other essential statutes to combat and prosecute illegal actions.

“This partnership puts criminals on notice that we will find them and stop them before they steal health care dollars,” Secretary Sebelius said.  “Thanks to this initiative today and the anti-fraud tools that were made available by the health care law, we are working to stamp out these crimes and abuse in our health care system.”

One innovative objective of the partnership is to share information on specific schemes, utilized billing codes and geographical fraud hotspots so that action can be taken to prevent losses to both government and private health plans before they occur. Another potential goal of the partnership is the ability to spot and stop payments billed to different insurers for care delivered to the same patient on the same day in two different cities. A potential long-range goal of the partnership is to use sophisticated technology and analytics on industry-wide healthcare data to predict and detect health care fraud schemes. 

“This partnership is a critical step forward in strengthening our nation’s fight against health care fraud,” said Attorney General Holder.  “This Administration has established a record of success in combating devastating fraud crimes, but there is more we can and must do to protect patients, consumers, essential health care programs, and precious taxpayer dollars.  Bringing additional health care industry leaders and experts into this work will allow us to act more quickly and effectively in identifying and stopping fraud schemes, seeking justice for victims, and safeguarding our health care system.”

The Executive Board, the Data Analysis and Review Committee, and the Information Sharing Committee will hold their first meeting in September.  Until then, several public-private working groups will continue to meet to finalize the operational structure of the partnership and develop its draft initial work plan.

The following organizations and government agencies are among the first to join this partnership:

• America’s Health Insurance Plans
• Amerigroup Corporation
• Blue Cross and Blue Shield Association
• Blue Cross and Blue Shield of Louisiana
• Centers for Medicare & Medicaid Services
• Coalition Against Insurance Fraud
• Federal Bureau of Investigations
• Health and Human Services Office of Inspector General
• Humana Inc.
• Independence Blue Cross
• National Association of Insurance Commissioners
• National Association of Medicaid Fraud Control Units
• National Health Care Anti-Fraud Association
• National Insurance Crime Bureau 
• New York Office of Medicaid Inspector General
• Travelers
• Tufts Health Plan
• UnitedHealth Group
• U.S. Department of Health and Human Services
• U.S. Department of Justice
• WellPoint, Inc.

The partnership builds on existing tools provided by the Affordable Care Act, resulting in:

• Tougher sentences for people convicted of health care fraud. Criminals will receive 20 to 50 percent longer sentences for crimes that involve more than $1 million in losses;
• Enhanced screenings of Medicare and Medicaid providers and suppliers to keep fraudsters out of the program.
• Suspended payments to providers and suppliers engaged in suspected fraudulent activity.

The administration’s efforts to date have already resulted in a record-breaking $10.7 billion in recoveries of health care fraud over the last three years. For more information on this partnership and the Obama administration’s work to combat health care fraud, please visit:

http://www.healthcare.gov/news/factsheets/2011/03/fraud03152011a.html

www.stopmedicarefraud.gov

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Note: All HHS press releases, fact sheets and other press materials are available at http://www.hhs.gov/news.

You can follow HHS on Twitter @HHSgov  and sign up for HHS Email Updates.

Last revised: July 26, 2012