Department of Justice Intensifies COVID Fraud Oversight

The U.S. Department of Justice recently announced that criminal charges have been filed against 21 defendants in multiple states for allegedly false billings and theft related to COVID-19 medical claims. 

Department of Justice Completes Major Operation

21 individuals in nine federal districts spread across the United States are facing charges for over $149 million in false healthcare billings and theft from pandemic assistance programs funded by the federal government. Over $8 million in cash was seized in connection with the operation by the Department of Justice’s Health Care Fraud Unit. 

“This COVID-19 health care fraud enforcement action involves extraordinary efforts to prosecute some of the largest and most wide-ranging pandemic frauds detected to date,” Director for COVID-19 Fraud Enforcement Kevin Chambers stated in a Department of Justice press release. “The scale and complexity of the schemes prosecuted today illustrates the success of our unprecedented interagency effort to quickly investigate and prosecute those who abuse our critical health care programs.”

This latest investigation follows a similar operation in May of 2021 with the aim of reducing healthcare fraud and overbilling related to COVID-19. 

Fraudulent Schemes Detailed in Announcement

The Department of Justice referenced several different cases and types of fraud in their announcement of this enforcement action. In multiple cases, defendants allegedly offered COVID-19 testing to patients in order to obtain their personal identifying information and saliva or blood samples. They then used that information to submit fraudulent claims to Medicare for unrelated and unnecessary tests or services. In other, similar cases, medical clinic owners obtained confidential information from patients seeking drive-through testing and then submitted fraudulent claims for lengthy office visits that never occurred. 

In Florida, a medical professional faces charges for a kickback scheme that involved billing for nonexistent telemedicine visits and genetic testing. This scheme has garnered attention from investigators in the past; last year, courts sentenced a defendant to 82 months in prison for a similar scheme. 

This operation also led to charges against two additional defendants for fraud schemes related to the Provider Relief Fund, a federal fund providing financial assistance to medical providers engaged in combatting COVID-19. A total of ten defendants have been charged with the misuse of PRF funds, three of which have either pleaded or been found guilty so far. 

“The attempt to profit from the COVID-19 pandemic by targeting beneficiaries and stealing from federal health care programs is unconscionable,” said Inspector General Christi A. Grimm, with the Department of Health and Human Services (HHS). “HHS-OIG is proud to work alongside our law enforcement partners at the federal and state levels to ensure that bad actors who perpetrate egregious and harmful crimes are held accountable.”

Administrative Action by the Department of Justice

In addition to the criminal charges levied by the FBI and other enforcement agencies, the Center for Program Integrity, Centers for Medicare and Medicaid Services (CPI/CMS) levied administrative actions against providers in relation to other fraud, waste, and abuse schemes. 

28 administrative actions were issued against providers for alleged fraudulent billing schemes related to COVID-19 care delivery, “We are committed to working closely with our law enforcement partners to combat fraud, waste and abuse in our federal health care programs,” stated Chiquita Brooks-LaSure, CMS Administrator. “The administrative actions CMS has taken protect the Medicare Trust Funds while also safeguarding people enrolled in Medicare.”

Vaccination Schemes

Charges were also filed against several individuals involved in the manufacture and distribution of falsified COVID-19 vaccine cards. These charges alleged that the individuals intentionally sought to obstruct the HHS and CDC in their efforts to administer a nationwide vaccination program. One defendant in northern California, for example, misused her position as the Director of Pharmacy at a hospital to obtain Moderna vaccine lot numbers that were then used to falsify vaccine cards. Another defendant in Washington State was charged as the ringleader of a multi-state distribution ring. 

Payment Integrity for Healthcare Payers

It’s important to note that, as seen here, federal enforcement of healthcare fraud, waste, and abuse tends to focus on Medicare and Medicaid issues. With $300 billion in fraud, waste, and abuse costs in the healthcare sector every year, federal efforts can only catch a small fraction of bad actors. 

For healthcare payers, a proven payment integrity partner like Alaffia Health is the key to avoiding medical overpayments due to F,W&A charges. Alaffia uses advanced AI technology to identify high-cost claims most likely to contain errors. Our expert team of analysts then reviews those claims for F,W,&A charges and contact the provider to arrange for the proper rate to be billed. 

Alaffia Health’s platform integrates seamlessly with your own systems, and our contingency-based fee means we only get paid for generating results. It only takes a few minutes to learn how we can begin preventing fraud, waste, and abuse charges for your organization immediately. Find out more today.