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busted: rounding up the top fraud schemes of Q2 2018

August 01, 2018

The nation’s top special investigators and law enforcement officials were hard at work stamping out the weeds of healthcare fraud and abuse this past spring. With help from the National Health Care Anti-Fraud Association, we’re sharing a compilation of the top allegations from April through June 2018, which involved false diagnoses, referral kickbacks, and medical taxi schemes.

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Nationwide opioid scheme: $2 billion 

Seventy-six physicians are among the 601 people who have been charged in what the U.S. Department of Justice calls the largest healthcare fraud bust ever. The defendants allegedly submitted fraudulent claims to Medicare, Medicaid, TRICARE, and private insurers for treatments that were either medically unnecessary or not provided at all. Several of those charged are accused of illegally distributing opioids and other prescription narcotics. The Justice Department noted that it leveraged data analytics to help catch the accused fraudsters. Thirty state Medicaid Fraud Control Units also participated in the bust.

California workers’ comp takedown: $580 million 

Three additional physicians have been accused of taking part in a 15-year-long healthcare fraud scheme that led to more than $580 million in fraudulent bills, mostly submitted to California’s workers’ compensation program. The doctors allegedly accepted kickbacks in exchange for referring to clinicians or performing several million dollars’ worth of surgeries at Pacific Hospital of Long Beach. Earlier this year, the owner of that hospital was sentenced to more than five years in prison for the scheme, which paid out more than $40 million in kickbacks to doctors and other medical professionals for spinal surgery referrals and procedures.

Texas false diagnosis scheme: $240 million 

A physician in southern Texas is accused of conspiring with others to falsely diagnose vulnerable patients with degenerative diseases, such as rheumatoid arthritis, then administering chemotherapy and other services to them based on those false diagnoses. The U.S. Attorney’s office says the physician then laundered the proceeds of the fraud scheme by investing in real estate through the United States and Mexico as well as buying private jets and other luxury vehicles. The scheme potentially hurt thousands of patients, including children and the elderly.

Michigan painkiller bust: $112 million 

A Detroit-area doctor is accused of prescribing more than 2.2 million pills—including dangerous opioids such as oxycodone and fentanyl—that were often medically unnecessary and later resold on the street. According to the indictment, the physician also submitted false claims to Medicare and Medicaid and conducted fraudulent and expensive injections to increase his revenue. He faces up to 40 years in federal prison if convicted.

New York Medicaid fraud: $6 million 

Federal officials have arrested a dozen people following a two-year investigation into Medicaid fraud in upstate New York. The defendants operated several medical taxi companies, allegedly billing Medicaid for trips that never took place and bribing patients with kickbacks to use specific taxi providers. Prosecutors say as much as 95 percent of some of the companies’ revenue was fraudulent.


As these alleged schemes demonstrate, payers need robust tools in their arsenal to weed out the ever-changing patterns of fraud, waste, and abuse (FWA). Learn how our real-time, pre-pay claim accuracy and pre- and post-pay FWA solutions, scalable for all sizes of payers, can drive 2 to 3 percent or more savings off your annual medical costs.

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As director of product marketing, Warren Lesnefsky is responsible for the go-to-market planning and execution of Verscend’s Payment Accuracy solutions. He brings nearly 20 years of healthcare marketing experience in leading cross-functional teams to successfully launch information technologies and analytic services to the payer and provider markets. Prior to joining Verscend in 2015, Warren held various marketing management roles at McKesson Health Solutions with a wide range of responsibilities covering events management, marketing communications, and product marketing. He holds a BA in Marketing from the University of Northern Colorado.

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