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$150M Healthcare Fraud (5 TAKEAWAYS)
The government targets opioid prescription abuses and billing unnecessary medical services as healthcare fraud.
What are the top law enforcement priorities in healthcare fraud investigations today?
The answer might vary depending on whom you ask.
However, we know of two healthcare fraud priorities that will not be receding any time soon: billing unnecessary medical services and opioid prescription abuse.
Law enforcement remains keenly focused on doctors overprescribing medications, referring patients to specialists for no reason, or billing for useless services.
This article spotlights a recent criminal case involving more than 21 defendants (12 doctors) and $150 million in fraudulent Medicare billings.
*Pro-Tip: Remember to consult criminal defense counsel for legal advice regarding any court case.
Prison Professors, an Earning Freedom company, works alongside criminal defense attorneys to help clients proactively navigate through white-collar cases and prosecutions.
According to the National Institute on Drug Abuse, nearly 50,000 Americans die annually due to opioid addiction. Physicians and other medical professionals write and fill opioid prescriptions everyday day, but in recent years there have been many highly publicized abuses.
In the current environment, the federal government will not hesitate to investigate and prosecute medical professionals to curb illegal and abusive conduct.
The Department of Health and Human Services’ Medicare Fraud Strike Force (or the Task Force) investigates healthcare fraud.
In 2018, based on the Task Force’s work, criminal charges came down against medical professionals from the Tri-County Wellness Group (Tri-County) in Michigan and Ohio.
The case revealed a brazen Medicare fraud scheme that lasted many years.The scheme involved doctors prescribing massive amounts of opioids to patients and also seeking fraudulent reimbursements from Medicare. In the end, Tri-County filed about 6.6 million Medicare reimbursement claims. None were valid because they were all deemed medically unnecessary.
Significantly, Tri-County doctors who claimed to be unaware of the Medicare billing scheme were prosecuted.
M. Rashid was the owner and CEO of Tri-County, a company operating healthcare facilities, pain clinics, and laboratories in Michigan and Ohio.
As CEO of Tri-County from 2008 to 2016, Rashid oversaw Tri-County’s regular policy to offer patients 30mg prescriptions of Oxycodone in exchange for accepting unnecessary and excruciating back injections. The unnecessary injections totaled more than 6.6 million doses.
“The specific injections used had nothing to do with the medical needs of the patients but were instead selected to be administered because they were the highest-paying injection procedures,” the Department of Justice (DOJ) said in a statement.
According to the DOJ, Tri-County physicians administrated pain injections to patients based exclusively on Medicare reimbursement rates. The evidence showed that Rashid even offered certain physicians a share of the Medicare reimbursements they could generate to encourage them to do more.
While some patients who visited the Tri-County clinics were legitimately suffering from pain, scores of others were drug dealers and opioid addicts. In fact, many of Tri-County’s patients lived in homeless shelters, one of many red flags in the case.
Even though some physicians at Tri-County claimed to be unaware of what was going on, the evidence presented at the trial showed that Rashid would only hire physicians who were willing to go along with the scheme. That evidence helped convict at least twelve Tri-County doctors.
DOJ also gathered evidence to show that Tri-County intentionally targeted the Medicare reimbursement program. The scheme was successful for a while. Remarkably, the government showed that Tri-County received more money for opioid injections than any other medical clinic in the United States.
When, at one point, Medicare suspended the medical billing privileges for one of Rashid’s pain clinics, Rashid created new shell companies and enrolled them with Medicare. He continued the scheme using these shell companies to launder the income.
Pro-Tip: Money laundering involves concealing the origins of money obtained illegally and funneling it through several legitimate operations.
As a result of the Task Force investigation and DOJ prosecution, Rashid pleaded guilty to one count of conspiracy to commit healthcare fraud and wire fraud, and one count of money laundering. Twenty-one others, including 12 physicians, are already convicted in connection with this case to date.
Based on Rashid’s role in the scheme, he received a 15-year prison sentence. Rashid’s sentence also includes a $51 million restitution order to repay Medicare and a forfeiture order of Rashid’s property. The forfeiture order includes more than $11.5 million in commercial and residential real estate.
Pro-Tip: Forfeiture means that the federal government seizes a defendants’ assets as part of the case, which are then typically auctioned off to pay part or all or a portion of any fines or restitution orders. Proceeds from forfeiture of personal property help offset the total amount of restitution that a defendant must pay. Criminal forfeitures can include personal property, commercial real estate (i.e., office buildings), and residential property (i.e., primary residence).
The Tri-County investigation is consistent with current law enforcement priorities in healthcare fraud. Indeed, Greenberg Traurig included unnecessary medical services and opioid prescription abuses in its 202 Outlook for Health Care Enforcement Trends. For full 2021 Outlook click here.
Pro-Tip: Greenberg’s outlook is consistent with our view that healthcare fraud investigations into medically unnecessary illegal prescriptions and unlawfully distributing opioids will keep rising. The False Claims Act (FCA) provides significant incentives for health care insiders to file a whistleblower case in the hopes of obtaining a large reward should the government prevail.
Whistleblower cases under the FCA will continue to play a significant role in healthcare fraud enforcement for the foreseeable future. FCA filings can provide a window into criminal investigations the federal government may be considering.
Other experts agree that billing unnecessary medical services and opioid prescription abuses will continue to be a focal point in healthcare fraud investigations.
- The government has robust tools and resources to investigate and prosecute healthcare fraud. No one in the healthcare industry should take the government’s focus on fraud lightly.
- From the DOJ’s perspective, one of the best tools against doctors and medical professionals who abuse the system is criminal prosecution. Medical professionals must keep abreast of law enforcement trends and tactics.
- Healthcare industry insiders can file whistleblower cases under the FCA. FCA cases often provide the DOJ with additional allegations to investigate. Under the FCA, whistleblowers have significant monetary incentives to come forward and expose what they know.
- The DOJ is likely to include money laundering charges in healthcare fraud cases like the Tri-County case.
- The government charged and convicted doctors who claimed to be unaware of the Medicare fraud scheme at Tri-County. And, as the Tri-County case shows, sentences in healthcare fraud cases can be severe. Medical professionals must be proactive and seek help if they become suspicious of any potential wrongdoing.
The Department of Justice continues to target these two types of healthcare fraud: billing unnecessary medical services and opioid prescription abuses. Many people are serving lengthy prison sentences for billing unnecessary services to government healthcare programs. More investigations and prosecutions are in the pipeline.
*Pro-Tip: Remember to consult criminal defense counsel for legal advice regarding any court case or investigation.