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When Santa made his list this past Christmas, the vast majority of healthcare providers were nice, but a small handful of them were … fraudy. Okay, that was a pretty bad joke, but not nearly as bad as the alleged healthcare fraud schemes that the National Health Care Anti-Fraud Association compiled from October through December 2017. Here’s our round-up of the top five busts made by the feds in recent months.
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Three defendants who collectively owned 10 diagnostic testing facilities in Brooklyn allegedly submitted false claims to Medicare, Medicaid, and other public healthcare programs over three years. The U.S. Attorney’s office says the trio paid kickbacks in exchange for patient referrals and misrepresented which company actually performed the services. They’re facing charges of healthcare fraud, making false claims to a federal agency, conspiracy to pay healthcare kickbacks, and money laundering.
A Texas fitness trainer allegedly misrepresented himself as a healthcare provider when submitting more than $25 million in fraudulent claims to insurance companies. The trainer, who offered in-home fitness training and therapy, was paid nearly $4 million over the past five years by large national health plans. He faces up to 10 years in prison.
A clinic owner and UPS driver were indicted in December for allegedly offering cash to patients for participating in a sleep study. According to the Justice Department, the sleep study tests were either medically unnecessary or not performed at all. As a result, the clinic billed various healthcare benefit programs, including those for UPS and Costco employees, more than $11 million. Each of the defendants is charged with 11 counts of healthcare fraud.
The federal government is suing Illinois-based SNAP Diagnostics, accusing the company of fraudulently billing Medicare for medically unnecessary sleep apnea testing and inducing physicians with kickbacks to refer all their home sleep testing services to the company. According to the lawsuit, SNAP only provided non-Medicare beneficiaries one night of testing but billed Medicare for up to three nights per beneficiary. Medicare began to cover home sleep testing in 2009.
Federal authorities say the owner of two physical therapy clinics defrauded the federal workers’ compensation program for services that weren’t provided as required. The clinics’ clients include federal agencies, primarily the U.S. Postal Service, serving patients in both Texas and Utah. The owner is also facing an identity theft charge for allegedly enrolling his clinics in the workers’ comp program by submitting a doctor’s license information without permission.
How can health plans fight potential fraud cases like these more effectively? Get our white paper about the provider decision quadrant, a decision-making framework that helps special investigative units target the right providers with the right message.