The Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint initiative between the federal Department of Health and Human Services (HHS), Office of the Inspector General (OIG), and the Department of Justice (DOJ), was created in 2009 and charged with investigating Medicare fraud and prosecution of offenders. Since its inception, HEAT has charged over 2,100 individuals involved in more than $6.5 billion in Medicare fraud. Its current conviction rate is approximately 95 percent, with an average jail sentence in excess of 4 years. For every dollar HEAT spends on investigations it recovers approximately eight dollars.
As recently as June of 2015, HEAT arrested more than 240 individuals—including doctors, nurses, pharmacists and other licensed professionals (as well as owners of healthcare providers)—for their alleged participation in Medicare fraud schemes involving approximately $712 million in false billings.
In Miami alone, 73 people were charged, as a result of this particular effort by HEAT, for schemes involving approximately $263 million in false billings for pharmacy, home health care, and mental health services.
HEAT focuses its efforts on nine locations: Baton Rouge; Brooklyn; Chicago; Dallas; Detroit; Houston; Los Angeles; Miami–Dade; and Tampa Bay.
Recently, a dramatic increase in subpoenas and search warrants, issued in investigations related to compounding pharmacies, has been observed. Moreover, the DOJ has made the recovery of Tricare funds from compounding pharmacies a priority, further raising the scrutiny of this healthcare sector.
Providers should review their compliance plans and business relationships to assure compliance with federal and state law. It is also important that providers review, on a monthly basis, the federal governments database of “Excluded Providers” to assure that none of their employees or agents are “Excluded.” Services provided or ordered by Excluded Providers are subject to recoupment.
OIG recently issued two reports following audits and evaluations, conducted by the OIG, that identify systemic weaknesses that make Part D fraud and abuse possible. These scathing OIG reports called into question both CMS and plan sponsors’ oversight of the Part D program and essentially demanded that CMS and plan sponsors increase audits of pharmacies.
The level of scrutiny being heaped on pharmacies is unprecedented.
If a provider finds that it has received an overpayment or has been involved in a non-compliant arrangement, the provide may be well be advised to utilize the government’s “Self Disclosure” program, that may spare the provider the most severe sanctions that the government can mete out.
Frier Levitt is well versed in representing healthcare clients that are the subject of governmental investigations. We work with clients in crafting strategies to mitigate the risk, and severity, of sanctions related to mishandling of government programs. If you need help with a government investigation or have questions regarding the government investigation process, contact Frier Levitt today.
