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August 17, 2011

Latest data show health care fraud as federal criminal hot-spot

This new report from the Transactional Records Access Clearinghouse, which is headlined "Health Care Fraud Prosecutions for 2011," highlights that the federal court, especially in southern Florida, are seeing many more health care fraud cases these days.  Here is the start of the TRAC report:

The latest available data from the Justice Department show that during the first eight months of FY 2011 the government reported 903 new health care fraud prosecutions. Already the activity this year exceeds the level for all of FY 2010.

Numbers were pushed higher by a series of investigations by the Federal Bureau of Investigations which led to prosecutions for health care fraud.  In Puerto Rico alone, 420 defendants have been charged this year.  Within the fifty states, the Southern District of Florida (Miami) led the nation in activity accounting for one out of every nine health care fraud prosecutions.

Across the nation if this activity continues at the same pace, the annual total of prosecutions will be 1,355 for this fiscal year. According to the case-by-case information analyzed by the Transactional Records Access Clearinghouse (TRAC), this estimate is up 85.4% over the past fiscal year when the number of prosecutions totaled 731.

For criminal justice researchers, I think this growing pocket of cases might be especially interesting to try to track from indictment through sentencing.  I sense that these health care fraud cases can often have lots of the most dynamic elements of case-processing discretion that can impact sentencing outcomes.  

For example, I suspect: that most of these prosecutions result in pleas (and with some defendants cooperating with the feds), but a few defendants go to trial; that these defendants have diverse roles in the crime and diverse backgrounds; that the amount of loss for sentencing purposes can be varied and will often be disputed; that arguments for departures and variances get different receptions in different courthouses.

August 17, 2011 at 10:59 AM | Permalink


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Criminals are not dumb. They know that, as inane as it sounds, Medicare regulations require that all bills submitted be paid no matter how facially bogus they appear. Who wouldn't "take their chances" under these circumstances?

The Feds could not begin to prosecute the 20- 30% of the Medicare submissions that are deemed fraudulent.

Posted by: mjs | Aug 17, 2011 7:13:58 PM

The immediately preceeding statement is not wholly accurate. If a Medicare claim is submitted and is technically complete/correct, it will be paid. The processing system/s has no capability to judge whether or not a billing provider is "facially bogus." In recent years, Medicare & Medicaid have improved their credialing aspects to try to weed out "bogus" providers from ever getting a billing number in the first place. However, no system is perfect. I would agree though that crooks are willing to play the odds considering the estimated amount of fraud that occurs and a correspondingly low number of prosecutions. Plea deals are very common in these cases.
(Retired former Medicare & Medicaid fraud investigator.)

Posted by: c g green | Aug 19, 2011 10:05:41 AM

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