AHLA U. How to Catch a Thief 101: A View from

 AHLA
U. How to Catch a
Thief 101: A View from
the Field
Maame A. Gyamfi
Senior Counsel
Office of Inspector General
US Department of Health and Human Services
Washington, DC
Lauren E. Mack
Chief, Healthcare Fraud Division
Kings County District Attorney’s Office
Brooklyn, NY
Thomas O’Donnell
Office of the Inspector General
US Department of Health and Human Services
New York, NY
Annual Meeting ● June 29-July 2, 2014
MEDICAID PROVIDER FRAUD
Presentation by:
ADA Lauren Mack-KCDA
Special Agent in Charge Tom O’Donnell—HHS-OIG
HEALTH CARE FRAUD UNIT
• Created to investigate allegations of fraud, waste,
and abuse of the Medicare and Medicaid programs
• Concentration on Health Care Fraud – (however,
includes Food Stamp fraud and Public Assistance
fraud)
• Comprised of dedicated attorneys, financial
investigators, paralegals and detective
investigators
• Collaborates with HHS-OIG, OMIG, SNP, NYC
HRA
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Types of Investigations
• Medicaid and Medicare Fraud
• Focus on the providers and beneficiaries
• Pharmacy owners, doctors, medical supply
companies, clinics
• Common criminal charges:
– Corruption (kickback payments for referrals)
– Billing for services that were never rendered
– Systematic overbilling (aka upcoding)
Types of Schemes
• SCHEME: (paid/professional benes)
– Clinic owners pay patients to frequent their
offices/facilities
– Recruiters aggressively incentivize card holders
– Excessive services then billed to Medicare and
Medicaid
• SCHEME: (services not rendered)
– Doctors / medical supply owners exploit
electronic claims process
– Submit thousands of fraudulent claims, most
for services never rendered
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Types of Schemes
• PRESCRIPTION FRAUD
• Typical scam:
– Patient gets prescription for controlled and/or
non-controlled substances from corrupt doctor
– Patient gets prescription for the above from a
legitimate source and is medically legit
prescription
– Patient fills prescription and then turns pills
over to broker for payment
– Broker then either distributes pills on the street
or sells back to pharmacy
Types of Schemes
• SCHEME: (refills)
--Pharmacists will pay beneficiary cash to
NOT order/pick up refills—pharmacist will then
bill for refills. HIV meds very lucrative
• SCHEME: (DME)
--DME—billing for a more expensive item
than what was provided
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Types of Schemes
• DME--Diabetic Shoe/insert scam:
• False/misleading advertising – “free” shoes
• Lack of medical necessity – shoes are being
given to anyone with Medicare coverage,
regardless of whether they have diabetes and
actually need the shoes
• Billing for diabetic shoes while providing
cheaper, non-medical shoes (or OTC inserts
in lieu of heat molded custom made inserts.
U.S. DHHS-OIG-OI
•
Created by the Inspector General’s Act of 1978
•
Created to investigate allegations of fraud, waste, and abuse of agency
programs
•
Largest IG in the federal government
•
10 Investigative Regions (Boston, New York, Philadelphia, Atlanta,
Chicago, Dallas, Kansas City, San Francisco, Los Angeles, and Miami)
•
Approximately 410 Special Agents nationwide
Office of Investigations
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OI Responsibilities
• Conduct Investigations
– Criminal
– Civil
– Administrative
• Administrative Exclusions
– Mandatory
– Permissive
• Protective Operations
Office of Investigations
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OI Caseload
• Health Care
– Medicare Parts A, B, & C
– Medicare Part D
– Medicaid
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Child Support Enforcement
Grant & Contract Fraud
Special Investigations
Exclusions
Office of Investigations
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New York Regional Office
• Main Office-New York City (NYRO)
• Field Offices- Edison NJ, Albany, NY,
Buffalo, NY, and Puerto Rico
• One Special Agent in Charge and five
Assistant Special Agents in Charge
• Approximately 40 agents
Office of Investigations
Medicare Fraud Strike Force
• Staffed by Federal prosecutors, Special
Agents from OI, other Federal, State, and
local law enforcement agencies
• Able to identify potential fraud cases for
investigation and prosecution
• Recent national takedown: 95 arrests and
approximately 240 million in fraud
Office of Investigations
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Bay Medical
8686 Bay Parkway, Brooklyn
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Most successful Brooklyn Strike Force case
to date
Largest health care fraud case in the
Eastern District of New York
Originated as an SGS referral based on the
high amount of allergy testing
Multi-agency, long-term investigation
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Bay Medical
“the $77 million scheme”
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Physical therapy billed, massages provided
“Spa” treatments
Medically unnecessary test
Unlicensed technicians
“No show” medical directors
“No show” patients
KICKBACKS
Traditional Investigative
Methods
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Beneficiary interviews
Cooperators
Consensual Monitorings
Surveillance
Review Patient charts
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“I Don’t Know What You’re
Talking About”
Multiple Undercovers
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At least three times a week (12 weeks)
Physical therapy that wasn’t needed
Ambulette transports
“Pay day” every other Friday
$50 per visit. “Pay day” would be $300
Title III wire tap initiated on May 2010
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Irina S: 15 years, $51 million
Max: 2 ½ years, $51 million
45+ Years
Dr. Drivas: 12 ½ years, $51 million
in Prison
Yury K: 8 years, $10 million
Elena G: Awaiting sentencing
Sergey Z: 1 year, $300,000
More than
Larisa: 1 year, $75,000
$50 million in
Anatoly: 3 years, $100,000
restitution
Sergey S: 18 months, $80,000
Leonid Z: 6 months, $75,000
Veronika: No time, No $
Millions more in
Katherina: No time, $300,000
asset forfeiture
Dr. Wahl: Awaiting sentencing
Irina B: Awaiting sentencing
Bay Medical
IRINA S.
MAX
MONEY
LAUNDERING
KICKBACKS
IRINA B.
A
M
B
U
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E
T
T
E
S
DOCTORS
DRIVAS
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V & A Pharmacy
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Collaborative investigation-KCDA & HHSOIG
Fraud amount $790k
No refills dispensed-Pharmacist bought
HIV scripts from HIV patients for $$$
Plead guilty to Healthcare Fraud –both
owner and corporation.
14 undercover “shops” all audio/video
taped (clip).
PROOF ISSUESWho me?
• I was not there
• My billing person made an error
• New electronic billing is so hard to
understand—off one number
• It was an honest mistake, not a crime
(I’m a bad doctor not a criminal one)
• I am helping them kick-the-habit
• Extrapolation : “How do you know
what equipment I had in 2008”
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