On July 13th, the US Attorney’s office in Chicago busted nearly 400 people for health care fraud. The bust included $1.3 billion in fabricated billings. Of the 400 involved 115 were medical professionals – physicians, nurses and the like – from 41 districts nationwide. Five days after the major take down, Acting United States Attorney for the Northern District of Illinois, Joel Levin, announced the creation of the Health Care Fraud Unit, “dedicated to the prosecution of criminal health care fraud violations.” The unit will seek out prosecutions of all forms of health care fraud. That includes doctors who give false diagnoses to explain the use of costly tests, as well as providers who illegally alter billings. Five prosecutors have been assigned to the unit. Those prosecutors will be led by Assistant U.S. Attorney Heather McShain.
The Recent Take-Down
The July 13th crackdown marked the largest of its kind in the history of the DOJ. Fifty-six doctors were charged during the bust. One-hundred defendants were specifically tied to opioid-related charges. In a press conference following the event, Attorney General Jeff Sessions said the following: “Too many trusted medical professionals like doctors, nurses and pharmacists have chosen to violate their oaths and put greed ahead of their patients,” adding, “They seem oblivious to the disastrous consequences of their greed.”
The crackdown involved a variety of different operations. In a case involving two chiropractors, $1.1 million was discovered to have been fraudulently added to a bill submitted to Blue Cross Blue Shield. To fabricate the billings, the practitioners added services that were never provided. As a result, they were able to pocket the extra money.
Sacred Heart
Even before the recent take-down, the US Attorney’s office in Chicago had been involved in a ten-year long investigation regarding fraudulent activity at Sacred Heart Hospital in Chicago. DOJ investigators discovered that people at the top of the organization were offering incentives (i.e. bribes) to physicians to persuade them to point patients toward Medicare and Medicaid services. Some of the top-most officials were indicted. Even the owner and CEO of the hospital, Edward Novak, was charged and convicted. In 2015, he was sentenced to four and a half years in prison and fined $770K in addition to $10.4 million in forfeiture. In 2013, the hospital was shut down.
How to Know
All of this begs the question: how is a patient supposed to know if his or her doctor is involved in fraudulent activity? Well, the sad fact is that there really is no way to know for sure. Take the story recounted by Evan Sweeney on FierceHealthCare.com.
Bill McColl, a producer for Yahoo! Finance, had no clue his doctor was involved in a scheme led by Biodiagnostic Laboratory Services LLC (BLS) – a scheme that included at least 36 doctors. McColl’s physician, Eugene DeSimone, was given a bribe of $1,500 a month to send blood samples to BLS. After about two years of bribes, he was sentenced to 37 months in prison.
McColl and his wife barely noticed anything amiss. DeSimone was distracted at times. But that’s about it. According to Sweeney, patients will have to wait until more data is available before being able to confidently choose a doctor that is both skilled and ethical.
How to Solve Health Care
In the meantime, we have the Justice Department’s new Health Care Fraud Unit and the even newer Opioid Fraud and Abuse Detection Unit, which focuses primarily on “individuals that are contributing to [the] prescription opioid epidemic.” These units are meant to protect patients from “unnecessary or unsafe medical procedures” and to prevent “millions of dollars in losses to Medicare and private insurers.” But is a crime unit the right solution to these problems?
As noted by Patrick Cotter, a defense attorney who represents medical professionals, “I think it is no accident that the current administration would look hard to prosecute and publicize any fraud they can find in the current health care system while at the same time fighting to reduce the government’s role and financial support for that health care system.” Instead of putting effort toward fixing a broken health care structure, the current administration is waging war against health care tout court.
Thus, it would appear the DOJ is continuing a longstanding tradition of solving public health issues with criminal prosecution.
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