A hearing titled Anatomy of a Fraud Bust: From Investigation to Conviction held by the Senate Committee on Finance (Committee) on April 24th allowed federal health care agencies to both tout their fraud-fighting successes, and defend their failure to implement all of the fraud-fighting initiatives created by the Affordable Care Act (ACA).  As a starting point, the government witnesses called to testify discussed two fraud enforcement success stories: the September 7, 2011 nationwide roundup of 91 individuals accused of health care fraud offenses in 8 cities involving approximately $295 million in false billing to federal health care programs and the ABC Home Health and Florida Home Health (ABC/Florida) case from the Southern District of Florida.  Afterwards, the government witnesses fielded questions from the Committee members about the government’s plans going forward in the health care fraud prevention and enforcement arenas.   The hearing coincided with the Government Accountability Office’s release of a report on implementation by the Centers for Medicare & Medicaid Services (CMS) of  provider screening efforts to prevent ineligible providers from fraudulently accessing Medicare and Medicaid payments. 

The Committee members, witnesses, and their testimonies, where available, were:

Members Present

Chairman Max Baucus (D-MT), Ranking Member Orrin Hatch (R-UT), and Senators Tom Carper (D-DE), Tom Coburn (R-OK), Charles Grassley (R-IA), Bill Nelson (D-FL), and Ron Wyden (D-OR) participated in the hearing.

Witnesses

• The Honorable Daniel Levinson, Inspector General, Office of Inspector General, Department of Health and Human Services, Washington, D.C.
• The Honorable Wifredo A. Ferrer, U.S. Attorney for the Southern District of Florida, Miami, Florida
• Dr. Peter Budetti, Deputy Administrator and Director of the Center for Program Integrity, Centers for Medicare & Medicaid Services,  Department of Health and Human Services, Washington, D.C.
• Ms. Kathleen King, Director, Health Care, United States Government Accountability Office, Washington, D.C.

During the Q&A session, the Senators asked various questions about the biggest fraud-producing areas in health care and government efforts to prevent and detect rather than “pay and chase” alleged fraud.  Of note, Senator Hatch’s statement set the tone for many of the questions that leveled criticism at CMS’s failure to implement any moratoria on new providers in certain industries or surety bonds for home health agencies, and the lack of results from data analysis initiatives aimed at catching fraudsters earlier in the course of their schemes. 

Overall, the government continues to be under significant pressure to deliver results under its strengthened health care fraud enforcement powers under the ACA.  And Senator Coburn’s assertion that the government should emphasize the potential jail time providers could face if convicted of fraud may have set the stage for further fraud takedowns and longer sentences in health care fraud cases.   The attorneys in our Health Care Enforcement Defense Group (HCEDG) recently published a three-part year in review series on important trends in this area, and the first quarterly report building upon this series will be released soon.