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 1 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 2 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 3 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 4 OI Responsibilities • Conduct Investigations – Criminal – Civil – Administrative • Administrative Exclusions – Mandatory – Permissive • Protective Operations Office of Investigations 9 OI Caseload • Health Care – Medicare Parts A, B, & C – Medicare Part D – Medicaid • • • • Child Support Enforcement Grant & Contract Fraud Special Investigations Exclusions Office of Investigations 10 5 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 12 6 Bay Medical 8686 Bay Parkway, Brooklyn     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 7 Bay Medical “the $77 million scheme”        Physical therapy billed, massages provided “Spa” treatments Medically unnecessary test Unlicensed technicians “No show” medical directors “No show” patients KICKBACKS Traditional Investigative Methods      Beneficiary interviews Cooperators Consensual Monitorings Surveillance Review Patient charts 8 “I Don’t Know What You’re Talking About” Multiple Undercovers       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 9               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 L E T T E S DOCTORS DRIVAS 10 V & A Pharmacy      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” 11