June 09, 2012

Health Care Fraud Prevention and Enforcement Action Team (HEAT)

There Is A New Sheriff In The Town The New Health Care Police:

By Melvin J. Howard

In May 2009, DOJ and HHS announced the creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT). With the creation of the new HEAT team the fight against Medicare fraud has become a Cabinet-level priority. Secretary Kathleen Sebelius and Attorney General Eric Holder pledge to continue fighting waste, fraud and abuse. As of today, DOJ and HHS continue to make progress and succeed in the fight against Medicare fraud.The joint DOJ-HHS Medicare Fraud Strike Force is a multi-agency team of federal, state and local investigators designed to combat Medicare fraud through the use of Medicare data analysis techniques and an increased focus on community policing. Health care fraud costs the country an estimated $80 billion a year. And it’s a rising threat, with national health care spending topping $2.7 trillion and expenses continuing to outpace inflation. Recent cases also show that medical professionals are more willing to risk patient harm in their schemes.

Healthcare fraud represents a serious threat to the quality of care and the delivery of healthcare to those in need. The victims of identity theft may have their medical records falsified to include incorrect information on blood types, allergies and other aspects of patients’ medical profiles. Some people have died after being given counterfeit prescription drugs, it can cost you your life. An FBI financial crimes report stated that, “One of the most significant trends observed in recent healthcare fraud cases includes the willingness of medical professionals to risk patient harm in their schemes. FBI investigations in several offices are focusing on subjects who conduct unnecessary surgeries, prescribe dangerous drugs without medical necessity, and engage in abusive or sub-standard care practices.”

Healthcare fraud has numerous insidious side effects that cannot be seen until years after the crime is perpetrated. For instance, doctors will likely prescribe an incorrect medical treatment based on information from a falsified medical record. The same record may prevent the patient from obtaining individual health insurance. More frustratingly, medical identity theft may reduce the victim’s health insurance benefits.

Fraud and corruption occurs in all systems

Fraud and corruption occur whether systems are predominantly public or private, well-funded or poorly funded, and technically simple or sophisticated. 

Fraud and corruption activities can take place in any area of healthcare delivery

The following processes stand out as having a high inherent risk of corruption 
1.       provision of services by medical personnel
2.       human resources management
3.       drug selection and use
4.       procurement of drugs and medical equipment
5.       distribution and storage of drugs
6.       regulatory systems, and
7.       budgeting and pricing

A study by the European Healthcare Fraud and Corruption Network (EHFCN) and the Center for Counter Fraud Services (CCFS) at Britain's Portsmouth University found that 5.59 percent of annual global health spending is lost to mistakes or corruption."Every euro lost to fraud or corruption means that someone, somewhere is not getting the treatment that they need," said Paul Vincke, EHFCN's president and one of the report's authors."They are ill for longer, and in some cases they simply die unnecessarily. Make no mistake -- healthcare fraud is a killer."

The report reviewed 69 exercises in 33 organizations in six countries to measure healthcare fraud and error losses.The combined expenditure assessed was more than 300 billion pounds ($490 bln) and the experts extrapolated their findings from Britain, the United States, New Zealand, France, Belgium and the Netherlands to get a global picture. The report found evidence for many different types of fraud, from pharmacists dividing prescriptions into small packages to claim extra fees, to drug companies organizing price cartels, to doctors over claiming travel costs and abusing government grants, to patients making fraudulent insurance claims.Two doctors were found to have claimed a government improvement grant for their clinic which they then spent on setting up a car import-export business.

The European Healthcare Fraud and Corruption Network (EHFCN) was set up to help the region's healthcare organizations find and cut losses on fraud and error so that more money could be better spent on patient care.