Sustained Outrage

Health care fraud convictions help recover billions

U.S. Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius announced today that joint efforts by the Department of Justice and Health and Human Services recovered more than $2.5 billion for the Medicare Trust Fund during the fiscal year 2009. This represents an increase of more than $500 million from the previous year.

“Over the years, we’ve seen that as long as health care fraud pays and goes unpunished, our health care system will remain under siege,” Holder said at a press conference. “These crimes harm all of us — government agencies and programs, insurers and health care providers, and individual patients. But we are fighting back.”

The Department of Justice also won or negotiated $1.6 billion in judgments and settlements, Holder said.

The Justice Department’s Criminal Division and our U.S. Attorneys’ Offices opened more than 1,000 new criminal health care fraud investigations and had more than 1,600 health care fraud criminal investigations pending. We reached an “all-time high” in the number of health care fraud defendants charged, with more than 800 indictments in nearly 500 cases and close to 600 convictions. And the Justice Department’s Civil Division opened nearly 900 new civil health care fraud investigations and had more than 1,100 pending cases.

The Health Care Fraud and Abuse Control Program’s annual report, which you can read here, does not break the money or cases down by state, so we don’t know how much of that may have come from West Virginia. But last November, in announcing that his office had recovered $8 million in the last fiscal year, Charles Miller, U.S. Attorney for the Southern District of West Virginia, said that nearly $1 million came from frauds against federal health care programs such as Medicare and Medicaid.

I mention this because over the last year or so, there have been several high-profile investigations into alleged wrongdoing at several medical facilities in West Virginia, including Justice Medical Clinic on the border of Wayne and Mingo counties and Mountain Medical Care Center in Williamson. The teeth of the Justice Medical prosecution (no criminal charges have been filed against anyone associated with Mountain Medical, although authorities raided the facility in March) was health care fraud.

It can be notoriously difficult to prove that, say, a doctor knowingly prescribed pain pills to an addict; the doctor can always argue that he or she was legitimately trying to treat a patient’s ongoing pain. If a patient lies about an ongoing pain issue, how is the doctor supposed to know? But it’s often harder for a doctor to explain why a medical facility billed a federal program for services that he or she didn’t provide, which constitutes health care fraud.

The lead investigator in the Justice Medical probe? A special agent with the U.S. Department of Health and Human Services.

In addressing the National Institute on Health Care Fraud in Miami today, acting deputy Attorney General Gary G. Grindler elaborated on why detecting and preventing health care fraud remains such an important issue:

Now, let me be clear: We know that most health care providers are doing the right thing. We know that most drug and device manufacturers are doing the right thing. They’re working hard everyday to develop drugs that will save and improve lives. They’re working to strengthen compliance efforts throughout a product’s lifecycle — and many of you in this room are helping companies dojust that. They’re instituting best practices to meet an evolving regulatory landscape while at the same time maximizing innovation.

We know that most players in this industry are honest participants in a complicated system. Yet we also know that there are those who seek to take advantage of that system at the expense of the nation’s taxpayers. And it is those actors who will draw our attention and bear the consequences of our enforcement.

But perhaps most important is that cases like this remind us that our fight against health care fraud is about more than dollars and cents; it’s about trust. The trust patients put in their health care providers to give them advice untainted by kickbacks or financial interest. The trust of the American people to spend their tax dollars wisely and protect them from waste, fraud and abuse. The trust consumers place in drug manufacturers to be honest in the claims they make about the drugs they sell. The trust those who rely on our public health programs have in the integrity of those programs to operate in ways that will keep them healthy, not expose them to harm.

This sacred trust is undermined whenever health care fraud goes unaddressed. So preventing health care fraud is a job that belongs to all of us — prosecutors and professionals; investigators and corporate counselors — all of us have a stake in protecting the integrity of our public health care programs. Because working together to combat fraud, we can keep and enhance that public trust. We can bring down the costs of health care. We can ensure the integrity of our public health care programs, and we can help create a system that works well and efficiently for all of us.