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Pondera FraudCast

Welcome to the Pondera FraudCast, a weekly blog where we post information on fraud trends, lessons learned from client engagements, and observations from our investigators in the field. We hope you’ll check back often to stay current with our efforts to combat fraud, waste, and abuse in large government programs.

Largest Health Care Fraud Bust in History

Largest Health Care Fraud Bust in History

Last week, the Department of Justice announced that they had made the largest “National Health Care Fraud Takedown” in history. In all, the DOJ brought charges against 412 people in 30 states responsible for $1.3 billion in false billings. Those charged included 115 doctors, nurses, and other licensed health care providers.

Many of those busted included operators of clinics that were alleged to be illegally distributing prescription opioids—a subject that we address all too often in this blog. One Houston clinic simply sold the opioids to a room packed full of addicts and drug dealers. Another clinic in Palm Beach, FL recruited addicts by offering them drugs and visits to strip clubs. There were even cases of single doctors prescribing more medications than entire hospitals.

In their press release, the DOJ points out that 59,000 Americans died last year from opioid related drug overdoses. Many of these were from prescription opioids. This is clearly a growing problem in our country and we applaud the DOJ, HHS, and law enforcement for their efforts in this takedown. This, and similar busts, should send a strong message to the bad actors in America’s health care system.

It is important to note, however, that we still have a lot of work ahead of us. As large as these takedown numbers are, one must consider that they still represent only a small percentage of the problem. The government’s own Paymentaccuracy.gov website assigns $96 billion per year in overpayments for Medicare Fee-for-Service, Medicaid, Medicare Advantage (Part C), and the Medicare Prescription Drug Benefit (Part D). So even if all of the $1.3 billion from this bust was falsely billed in one year (which it wasn’t), it would still represent only 1.35% of the total estimated problem.

I, for one, am hoping that this is simply one of many steps in the right direction.

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Pondera leverages advanced prediction algorithms and the power of cloud computing to combat fraud, waste, and abuse in government programs.



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