HEAT: A Year of Tackling Health Care Fraud

Every day, the nation’s health care system is victimized by health care fraud perpetrators intent on lining their own pockets at the expense of the American taxpayer, patients, and private insurers. This not only drives up costs for everyone in the health care system, it hurts the long term solvency of Medicare and Medicaid, two programs upon which millions of Americans depend. In May 2009, Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius announced the creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) and renewed their commitment to fighting health care fraud as a Cabinet-level priority at both departments. The mission of HEAT is clear:

• To marshal significant resources across government to prevent waste, fraud and abuse in the Medicare and Medicaid programs and crack down on the fraud perpetrators who are abusing the system and costing us all billions of dollars.
• To reduce skyrocketing health care costs and improve quality of care by ridding the system of perpetrators who are preying on Medicare and Medicaid beneficiaries.
• To highlight best practices by providers and public sector employees who are dedicated to ending waste, fraud and abuse in Medicare.
• To build upon existing partnerships that already exist between the two agencies, including our Medicare Fraud Strike Forces to reduce fraud and recover taxpayer dollars.

Our work is making a significant difference. In FY2009, the Department of Justice (DOJ), including its 94 U.S. Attorneys’ Offices, HHS’s Office of the Inspector General, and the Centers for Medicare and Medicaid Services (CMS) worked together to file charges involving criminal health care fraud violations against more than 800 defendants, secure 583 criminal convictions, open 886 new civil health care fraud investigations, obtain 337 civil administrative actions against individuals and organizations who were committing Medicare Fraud, and recovered more than $2.5 billion in criminal, civil and administrative actions related to our joint health care fraud enforcement activities. The success of HEAT’s collaboration has been recognized by President Barack Obama, whose FY2011 budget request includes an additional $60.2 million to allow the Strike Forces to continue to expand into additional cities in the near future. As part of ongoing HEAT activities, Attorney General Holder and Secretary Sebelius recently sent a letter to all state attorneys general urging them to work with HHS and federal, state and local law enforcement officials to mount a substantial outreach campaign to educate seniors and other Medicare beneficiaries about how to prevent scams and fraud beginning this summer. In the letter, the Attorney General and Secretary outline education and outreach efforts where state attorneys general could make a significant difference. HEAT’s creation and ongoing collaboration has allowed top-level law enforcement agents, criminal prosecutors and civil attorneys, and staff from DOJ and HHS to examine lessons learned and innovative strategies in our efforts to both prevent fraud and enforce current anti-fraud laws around the country. Since its creation in May 2009, HEAT has focused on key areas for coordination and improvement. HEAT members are working to identify new enforcement initiatives and areas for increased oversight and prevention to increase efficiency in pharmaceutical and device investigations. This includes close collaboration with DOJ’s Civil Division and U.S. Attorneys’ Offices, HHS’s Office of the Inspector General and the Food and Drug Administration. Medicare Fraud Strike Forces, which include teams from DOJ’s Criminal Division and U.S. Attorneys’ Offices, the FBI, CMS and HHS’s Office of the Inspector General have expanded from the launch sites of South Florida (2007) and Los Angeles (2008) to Houston, Detroit, Brooklyn, Baton Rouge and Tampa. Since announcing HEAT in May 2009, the Medicare Fraud Strike Forces have charged 465 defendants with defrauding Medicare of more than $830 million taxpayer dollars. In the three years since they were created, Medicare Fraud Strike Forces have charged more than 810 defendants with defrauding Medicare of nearly $1.9 billion taxpayer dollars. Since the False Claims Act was significantly amended in 1986 through FY 2009, DOJ’s Civil Division and U.S. Attorneys’ Offices have recovered nearly $16 billion in matters alleging fraud against government health care programs. . DOJ’s Civil Division and U.S. Attorneys’ Offices have recovered more than $3.6 billion in health care fraud matters pursued under the False Claims Act and Food, Drug and Cosmetic Act since HEAT was announced. As a primary tool in finding fraudulent activity, DOJ and HHS have expanded data sharing and improved information sharing procedures in order to get critical data and information into the hands of law enforcement to track patterns of fraud and abuse, and increase efficiency in investigating and prosecuting complex health care fraud cases. A cross-government health care fraud data intelligence sharing workgroup has been established to share fraud trends, new initiatives, ideas and success stories to improve awareness across the government of issues relating to health care fraud. Both departments have worked to increase training to prevent honest mistakes and help stop potential fraud before it happens. This includes CMS compliance training for providers, ongoing meetings at U.S. Attorneys’ Offices with the public and private sector, and increased efforts by HHS to educate specific groups – including elderly and immigrant communities – to help protect them. CMS has also expanded several of their programs, including a demonstration project on Durable Medical Equipment and their Medicaid provider audit program, to help monitor activities and detect fraud. Recognizing that training is also necessary for investigative and law enforcement personnel, both agencies have also increased opportunities within their departments. In November 2009, DOJ conducted Medicare Fraud Strike Force training, which was designed to teach the Strike Force concept and case model to prosecutors, law enforcement agents and administrative support teams. CMS and the HHS Office of the Inspector General are also providing ongoing training to DOJ and HHS staff on the use of new technology to catch and quickly turn off funding to those who are defrauding the system. In January 2010, the first “National Summit on Health Care Fraud” was held to bring together leaders from the public and private sectors to identify and discuss innovative ways to eliminate fraud, waste and abuse in the health care system. HHS established the CMS Center for Program Integrity (CPI) in April 2010 to apply innovative methods and technology to prevent fraud, and to ensure that correct payments are made to legitimate providers for appropriate and reasonable services for eligible beneficiaries of the Medicare and Medicaid programs.