Advanced Computer System Used To Crack Down on Medicare Fraud

June 20, 2015 in News

The Department of Justice used advanced computer programs to help identify potential Medicare fraud and bring charges against nearly 250 people, including 46 providers, who falsely billed Medicare a total of nearly $712 million, the Wall Street Journal reports.

Details of Charges

U.S. Attorney General Loretta Lynch said the charges represented the “largest criminal health-care fraud takedown in the history of the Department of Justice” (Barrett, Wall Street Journal, 6/18).

The cases are being handled by the Medicare Fraud Strike Force, which has charged more than 2,300 people accused of falsely billing Medicare more than $7 billion since it was established in 2007. The Affordable Care Act bolstered the strike force with $350 million in additional funding (Bernstein/Horwitz, Washington Post, 6/18).

Lynch said the individuals who were charged “billed for equipment that wasn’t provided, for care that wasn’t needed and for services that weren’t rendered” (Alonso-Zaldivar, AP/Washington Post, 6/18).

More than 44 of the 243 suspects allegedly defrauded Medicare Part D, marking the first major crackdown on fraud of the prescription drug benefits program for seniors.

Computer Program Details

Federal officials said the arrests were aided by increasingly sophisticated computer programs that scan billing data for potential fraud (Wall Street Journal, 6/18).

Assistant Attorney General Caldwell said, “We obtain and analyze billing data in real-time. We target hot spots — areas of the country and the types of health care services where the billing data shows the potential for a high volume of fraud — and we are speeding up our investigations” (DOJ release, 6/18).

FBI Director James Comey said investigators “followed the money” to uncover individuals who saw Medicare as “an ATM that was a freebie to them but is actually filled with taxpayers’ money” (Washington Post, 6/18).

Jessica Gustafson, a lawyer from the Health Law Partners, said the announcement could signal that the government is set to more aggressively fight Medicare Part D fraud (Schenker, Modern Healthcare, 6/18).

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