Health Care Fraud Trends and Tips

A pharmaceutical company marketed four drugs to doctors. The drugs had been approved by the Food and Drug Administration (FDA) for specific medical conditions—like rheumatoid arthritis, schizophrenia, and neuropathic pain—but the company promoted the drugs for other uses as well—like post-operative pain, dementia, and migraines—and sometimes in larger doses than the FDA allowed. In some cases, the company even paid kickbacks to doctors to prescribe the drugs for these other uses.

What this company did is known as off-label marketing of prescription drugs, and it’s both illegal and potentially harmful to consumers. After an investigation involving the FBI and our federal and state partners, the company pled guilty to misbranding the drugs and agreed to pay $2.3 billion to settle criminal and civil violations…the largest U.S. health care fraud settlement ever.

At the FBI, we take our health care fraud responsibilities seriously as the primary investigative agency with jurisdiction over both federal and private insurance programs. But with total health care expenditures in the U.S. expected to reach $2.26 trillion by 2016 according to the Centers for Medicare and Medicaid Services, the opportunity for fraud will continue to grow—so will our workload. That means we have to find ways to leverage our resources.

Partnerships are key. A tried-and-true method of leveraging resources is establishing partnerships. And we’ve done just that—with federal agencies like the FDA and the Drug Enforcement Administration, various state and local agencies, and private insurance groups like the National Health Care Anti-Fraud Association.

Our most recent joint endeavor? Our participation in the Department of Justice/Health and Human Services’ (HHS) Health Care Fraud Prevention and Enforcement Action Team, or HEAT, and its Medicare Fraud Strike Forces located in several major metropolitan areas.

The HEAT initiative includes senior Justice, FBI, and HHS officials who are focusing their efforts to reduce Medicare and Medicaid fraud through enhanced cooperation. And the strike forces, which use a data-driven approach to identify unexplainable billing patterns by health care providers and then investigate these providers for possible fraudulent activity, are a vital part of the initiative. As a result of strike force efforts, more than 300 cases have been filed and close to 600 defendants charged.

Health care fraud facts:

• Health care fraud schemes come in all forms—fraudulent billings, medically unnecessary services or prescriptions, kickbacks, duplicate claims, etc.
  Schemes target large health care programs—both public and private—as well as health care beneficiaries. (Medicare and the Medicaid are the largest programs, so they are targeted more often.)
• Schemes are committed by health care providers, owners of medical facilities and laboratories, suppliers of medical equipment, organized crime groups, corporations, and even sometimes by the beneficiaries themselves.
• FBI health care fraud cases sometimes cross over into other investigative areas, like organized crime, gangs, and cyber crime, where we see criminals beginning to use the proceeds from health care fraud schemes to fund their operations.

Tips to help avoid being victimized:

• Protect your health insurance information card like a credit card.
• Beware of free health services—are they too good to be true?
• Review your medical bills, like your “explanation of benefits,” after receiving health care services and ensure the dates are services are correct.

And if you suspect health care fraud, contact your local FBI office.

Original notification posted by the Federal Deposit Insurance Corporation (FDIC), which is an independent agency created by the Congress to maintain stability and public confidence in the nation’s financial system by:

• insuring deposits,
• examining and supervising financial institutions for safety and soundness and consumer protection, and
• managing receiverships.