By The Division of Justice on Wednesday charged 345 individuals, together with medical doctors, nurses and different medical professionals, throughout 51 federal districts in what the company is asking the biggest healthcare fraud takedown in historical past.
The fees are in connection to circumstances accounting for greater than $6 billion in losses, together with greater than $4.5 billion linked to telehealth.
Based on courtroom paperwork, 86 defendant telehealth executives allegedly paid medical doctors and nurse practitioners to order pointless sturdy medical gear, genetic and different diagnostic testing, and ache drugs, both with none affected person interplay or with solely a quick telephone dialog with sufferers they’d by no means met or seen.
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Sturdy medical gear firms, genetic testing laboratories, and pharmacies then bought these orders in alternate for unlawful kickbacks and bribes and submitted false and fraudulent claims to Medicare and different authorities insurers.
Along with the felony fees, the Facilities for Medicare and Medicaid Providers’ Middle for Program Integrity individually introduced that it has taken a variety of administrative actions associated to telehealth fraud, revoking the Medicare billing privileges of 256 further medical professionals for his or her involvement in varied schemes.
WHAT’S THE IMPACT
The telehealth fraud take-down is a realization of fears expressed by among the potential for billing fraud and abuse with the healthcare system when CMS lifted telehealth restrictions in the course of the pandemic.
Mike Cohen, an operations officer with the Well being and Human Providers Inspector Normal’s Workplace, informed Kaiser Well being Information in April that anti-fraud “guardrails have been eliminated below this epidemic. The priority is that issues won’t ever return to what they had been. … There shall be a variety of stress on CMS to make at the least a few of these adjustments everlasting.”
CMS is below that stress because the company, suppliers and payers weigh the long-term use of telehealth as its use has drastically elevated in the course of the pandemic.
WHAT ELSE YOU NEED TO KNOW
Defendants have been charged with greater than $845 million in alleged fraud linked to substance abuse remedy services, or “sober houses,” and greater than $806 million linked to different fraud and unlawful opioid distribution schemes throughout the nation.
The “sober houses” circumstances embrace fees towards greater than a dozen felony defendants in reference to greater than $845 million of allegedly false and fraudulent claims for exams and coverings for weak sufferers looking for remedy for drug and alcohol dependancy. These charged embrace physicians, homeowners and operators of substance abuse remedy services, in addition to affected person recruiters (referred to within the trade as “physique brokers”).
They’re alleged to have participated in schemes involving the cost of unlawful kickbacks and bribes for the referral of scores of sufferers to substance abuse remedy services. These sufferers had been subjected to medically pointless drug testing — typically billing hundreds of {dollars} for a single check — and remedy periods that had been regularly not offered, and which resulted in tens of millions of {dollars} of false and fraudulent claims being submitted to non-public insurers.
The circumstances involving the unlawful prescription and/or distribution of opioids, or that fall into extra conventional classes of healthcare fraud, embrace fees and responsible pleas involving greater than 240 defendants who allegedly participated in schemes to submit greater than $800 million in false and fraudulent claims to Medicare, Medicaid, TRICARE and personal insurance coverage firms for remedies that had been medically pointless and infrequently by no means offered.
THE LARGER TREND
There have been a variety of cases of fraud to this point in 2021. In July, 10 individuals had been indicted in connection to a scheme of utilizing rural hospitals throughout a number of states to allegedly invoice personal insurance coverage firms for fraudulent laboratory testing claims. The conspirators billed insurers roughly $1.4 billion for laboratory urinalysis drug exams and blood exams and had been paid about $400 million. This allegedly went on from the top of 2015 to the start of 2018.
In February, a doctor who was the highest prescriber of oxycodone in Michigan from 2016 to 2017 was charged with a $120 million healthcare fraud and cash laundering scheme that concerned the alleged medically pointless distribution of greater than 2.2 million doses of managed substances, and the administration of medically pointless injections. These purportedly resulted in affected person hurt.
