Federal and state law enforcement officials in West Virginia’s northern 32 counties recently announced investigative plans certain to target some medical providers in the region.  The officials have formed a “working group” to use “advanced statistical sampling” to proactively evaluate the providers’ health care reimbursement data.  By doing so, the law enforcement group “plans to identify potentially fraudulent billing patterns and uncover waste and abuse more efficiently.”

The group will target billers of federal health care programs, such as Medicare, Medicaid, TRICARE, as well as federal and state Workers’ Compensation systems.  Law enforcement agencies involved include:  the United States Department of Health and Human Services (DHHS); the Drug Enforcement Administration (DEA); the Federal Bureau of Investigation (FBI); the Internal Revenue Service-Criminal Investigations Divisions (IRS-CID); the West Virginia Medicaid Fraud Control Unit; the Ohio Medicaid Fraud Control Unit; the West Virginia Office of the Insurance Commission; and the Ohio Bureau of Workers’ Compensation.

Medical providers should continue to exercise care and due diligence in billing practices, as the group touts that its fraud detection tools allow identification of sophisticated schemes that may have escaped past scrutiny.  Our firm’s Health Care Practice Team has experience with the government’s use of statistical sampling in civil enforcement actions and criminal prosecutions of health care providers.