HEAT: A Year of Tackling Health Care Fraud

Every day, the nation’s health care system is victimized by health care fraud perpetrators intent on lining their own pockets at the expense of the American taxpayer, patients, and private insurers. This not only drives up costs for everyone in the health care system, it hurts the long term solvency of Medicare and Medicaid, two programs upon which millions of Americans depend.
In May 2009, Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius announced the creation of the Health Care Fraud Prevention and Enforcement Action Team (HEAT) and renewed their commitment to fighting health care fraud as a Cabinet-level priority at both departments.
The mission of HEAT is clear:

• To marshal significant resources across government to prevent waste, fraud and abuse in the Medicare and Medicaid programs and crack down on the fraud perpetrators who are abusing the system and costing us all billions of dollars.
• To reduce skyrocketing health care costs and improve quality of care by ridding the system of perpetrators who are preying on Medicare and Medicaid beneficiaries.
• To highlight best practices by providers and public sector employees who are dedicated to ending waste, fraud and abuse in Medicare.
• To build upon existing partnerships that already exist between the two agencies, including our Medicare Fraud Strike Forces to reduce fraud and recover taxpayer dollars.

Our work is making a significant difference. In FY2009, the Department of Justice (DOJ), including its 94 U.S. Attorneys’ Offices, HHS’s Office of the Inspector General, and the Centers for Medicare and Medicaid Services (CMS) worked together to file charges involving criminal health care fraud violations against more than 800 defendants, secure 583 criminal convictions, open 886 new civil health care fraud investigations, obtain 337 civil administrative actions against individuals and organizations who were committing Medicare Fraud, and recovered more than $2.5 billion in criminal, civil and administrative actions related to our joint health care fraud enforcement activities.
The success of HEAT’s collaboration has been recognized by President Barack Obama, whose FY2011 budget request includes an additional $60.2 million to allow the Strike Forces to continue to expand into additional cities in the near future.
As part of ongoing HEAT activities, Attorney General Holder and Secretary Sebelius recently sent a letter to all state attorneys general urging them to work with HHS and federal, state and local law enforcement officials to mount a substantial outreach campaign to educate seniors and other Medicare beneficiaries about how to prevent scams and fraud beginning this summer. In the letter, the Attorney General and Secretary outline education and outreach efforts where state attorneys general could make a significant difference.
HEAT’s creation and ongoing collaboration has allowed top-level law enforcement agents, criminal prosecutors and civil attorneys, and staff from DOJ and HHS to examine lessons learned and innovative strategies in our efforts to both prevent fraud and enforce current anti-fraud laws around the country.
Since its creation in May 2009, HEAT has focused on key areas for coordination and improvement. HEAT members are working to identify new enforcement initiatives and areas for increased oversight and prevention to increase efficiency in pharmaceutical and device investigations. This includes close collaboration with DOJ’s Civil Division and U.S. Attorneys’ Offices, HHS’s Office of the Inspector General and the Food and Drug Administration.
Medicare Fraud Strike Forces, which include teams from DOJ’s Criminal Division and U.S. Attorneys’ Offices, the FBI, CMS and HHS’s Office of the Inspector General have expanded from the launch sites of South Florida (2007) and Los Angeles (2008) to Houston, Detroit, Brooklyn, Baton Rouge and Tampa.
Since announcing HEAT in May 2009, the Medicare Fraud Strike Forces have charged 465 defendants with defrauding Medicare of more than $830 million taxpayer dollars.
In the three years since they were created, Medicare Fraud Strike Forces have charged more than 810 defendants with defrauding Medicare of nearly $1.9 billion taxpayer dollars.
Since the False Claims Act was significantly amended in 1986 through FY 2009, DOJ’s Civil Division and U.S. Attorneys’ Offices have recovered nearly $16 billion in matters alleging fraud against government health care programs. . DOJ’s Civil Division and U.S. Attorneys’ Offices have recovered more than $3.6 billion in health care fraud matters pursued under the False Claims Act and Food, Drug and Cosmetic Act since HEAT was announced.
As a primary tool in finding fraudulent activity, DOJ and HHS have expanded data sharing and improved information sharing procedures in order to get critical data and information into the hands of law enforcement to track patterns of fraud and abuse, and increase efficiency in investigating and prosecuting complex health care fraud cases.
A cross-government health care fraud data intelligence sharing workgroup has been established to share fraud trends, new initiatives, ideas and success stories to improve awareness across the government of issues relating to health care fraud.
Both departments have worked to increase training to prevent honest mistakes and help stop potential fraud before it happens. This includes CMS compliance training for providers, ongoing meetings at U.S. Attorneys’ Offices with the public and private sector, and increased efforts by HHS to educate specific groups – including elderly and immigrant communities – to help protect them. CMS has also expanded several of their programs, including a demonstration project on Durable Medical Equipment and their Medicaid provider audit program, to help monitor activities and detect fraud.
Recognizing that training is also necessary for investigative and law enforcement personnel, both agencies have also increased opportunities within their departments. In November 2009, DOJ conducted Medicare Fraud Strike Force training, which was designed to teach the Strike Force concept and case model to prosecutors, law enforcement agents and administrative support teams. CMS and the HHS Office of the Inspector General are also providing ongoing training to DOJ and HHS staff on the use of new technology to catch and quickly turn off funding to those who are defrauding the system.
In January 2010, the first “National Summit on Health Care Fraud” was held to bring together leaders from the public and private sectors to identify and discuss innovative ways to eliminate fraud, waste and abuse in the health care system.
HHS established the CMS Center for Program Integrity (CPI) in April 2010 to apply innovative methods and technology to prevent fraud, and to ensure that correct payments are made to legitimate providers for appropriate and reasonable services for eligible beneficiaries of the Medicare and Medicaid programs.

Ghostwriting Parades

Ghostwriting is a typical practice in the academic world and is not limited to the medical profession.

You have a broad range of special interest groups that can influence social policy from outside the elected officials office from a more indirect manner, and that is through benefactor activities.

You will find this in scholarships, fellowships, and most other funding initiatives. Take foster care for example. You have universities who set up their own child welfare institute who will only publish research that is beneficial to its federally funded revenue-maximization scheme due to the fact that most social work training in child welfare is funded through Title IV-B and E initiatives.

In this manner, the only authority to turn to becomes the only literary source of information. And that is how the imperialistic morality parade keeps marching along.

Propaganda at its finest.

Report Urges More Curbs on Medical Ghostwriting

Should more light be shed on the relationships between drug makers and certain prominent doctors who publish scientific articles about their medicines?

A new Congressional report calls on medical journals, medical schools and even the National Institutes of Health to take additional measures to ensure the integrity of the scientific articles many doctors rely on to make treatment decisions for their patients.

The report, issued Thursday by Senator Charles E. Grassley of Iowa, the ranking Republican on the Senate Finance Committee, focuses on medical ghostwriting.

Ghostwriting is the practice in which prominent researchers sign on as authors to articles for scientific journals that have been developed by third-party medical education companies at the behest of drug or medical device makers. Influential doctors listed as authors, the report said, have had varied input on articles drafted by industry-financed writers that have been published in medical journals.

“Manipulation of medical literature could lead physicians to prescribe drugs that are more costly or may even harm patients,” the report said.

Over the last few years, industry documents made public in government investigations and product liability lawsuits against drug makers have shown medical ghostwriting to be widespread.

In response, many medical journals have tightened their policies requiring authors to disclose industry funding and editorial assistance. Last year, the Pharmaceutical Research and Manufacturers of America, a drug industry trade group, revised its clinical research principles, adopting standards that ask authors to disclose industry contributions to research publications.

A number of drug makers have also changed their publication policies to acknowledge their supporting roles. Some leading medical schools, meanwhile, have added policies explicitly prohibiting faculty from signing on to ghostwritten articles.

But the senator’s report said a variety of scientific institutions, including the National Institutes of Health, should be more vigilant to ensure the integrity of the medical literature.

Even when articles in medical journals acknowledge industry-sponsored medical writers for “editorial assistance,” for example, the role of drug makers in such publications may remain unclear to readers, the report said. A drug maker may have initiated an article, chosen the medical writer, influenced the outline or draft before it is sent to an academic author for review, or vetted the final manuscript, before it is submitted to a medical journal, according to the report.

Senator Grassley recommended in a separate letter to Dr. Francis S. Collins, the director of the N.I.H., that applicants who apply for agency research grants should be required to disclose any industry support, whether financial or editorial, that they have received for articles.

A spokesman for the N.I.H. said the agency had received Mr. Grassley’s letter and would respond at a later date. It already is considering a new rule to increase disclosure of the financial sponsorship of researchers seeking grants.

Ghostwriting in Medical Literature

Attorney General Health Care Fraud Summit Speech

The following is the opening speech delivered by U.S. Attorney General Eric Holder at the January 28, 2010 National Health Care Fraud Summit.

Attorney General Eric Holder Speaks at the National Summit on Health Care Fraud

Washington, D.C. ~ Thursday, January 28, 2010

Good morning. I’m pleased to join Secretary Sebelius in welcoming you, and I thank you all for participating in today’s important discussion.

Let me also thank the National Institutes of Health for hosting us. It’s fitting that we’ve gathered at NIH, where some of our nation’s most innovative and collaborative thinking about health care is done. As we turn our attention to the problem of health care fraud – one of our most urgent, destructive, and widespread national challenges – we have an opportunity to build on the record of achievement that’s been established here.

Today’s summit marks a critical step forward in the work being done by HEAT, our Health Care Fraud Prevention and Enforcement Action Team. In establishing this task force last May, the Departments of Justice and Health and Human Services were inspired by common cause – and by common sense. We realized that we have a serious problem on our hands, and we decided it was time to redouble our efforts. We also recognized that the best way to strengthen our individual work is to combine forces and collaborate.

HEAT represents our shared commitment to combating health care fraud and, specifically, to protecting taxpayer dollars and our Medicare and Medicaid programs. But it’s more than just a partnership between our agencies. It’s evidence of this Administration’s commitment to fiscal responsibility and accountability. And, over the last eight months, it’s become proof that – with more effective communication and more efficient cooperation – we can make measurable, meaningful progress in the fight against health care fraud.

But we cannot do it alone. We need help from state and local leaders, and engagement from across the insurance industry and health care-provider community. There’s no question that our ability to protect taxpayer dollars, to ensure the viability of our government health care programs, and to strengthen our national health care system depends on our ability to expand the discussion beyond the federal government.

That’s what this summit is all about. Your presence here today is proof of a shared commitment aimed at identifying, punishing and preventing health care fraud. Secretary Sebelius and I are so grateful for your help in this joint effort. And we expect your insights and recommendations to help guide and enhance HEAT’s critical work.

So far, HEAT has fostered new opportunities for collaboration. It’s enhanced our ability to bring abuse to light and criminals to justice. And it’s enabled the recovery of stolen funds and the return of millions of dollars to the U.S. Treasury. Together, we must continue to build on these achievements.

As many of you know, last year brought record levels of achievement in our fight against health care fraud. In 2009, the Justice Department reached an all-time high in the number of health care fraud defendants charged, more than 800. We also obtained more than 580 convictions. And on the civil enforcement front, our health care fraud recoveries last year under the False Claims Act exceeded a stunning $2.2 billion dollars.

Many of these successes can be attributed to our Medicare Fraud Strike Forces, which are at the core of HEAT’s law enforcement mission. These strike forces supplement the enforcement activities of United States Attorneys’ Offices in select cities where unexplained, aberrant billing rates indicate that health care fraud may be especially high. By fostering increased cooperation and collaboration across our agencies, HEAT has enabled our strike forces to act with greater speed and efficiency to root out criminals who purport to operate as legitimate health care providers and suppliers.

Since HEAT was launched, our Medicare Fraud Strike Forces have been strengthened. In the last eight months, we’ve filed more than 60 cases. We’ve charged 200 offenders and secured more than 50 guilty pleas. And we’ve uncovered more than a quarter of a billion dollars in fraudulent billings.
I’m proud of this great work performed by our prosecutors, agents, analysts and investigators -- and by our partners at HHS. And I’m confident that we’re on the right path. That said, we cannot yet be satisfied. We cannot become complacent. And we cannot ignore the unfortunate fact that health care fraud remains a significant problem.

The scope of the problem is simply shocking. One estimate suggests that more than $60 billion in public and private health care spending is lost each year to health care fraud. That is a staggering amount of money. It’s half the entire economy of Secretary Sebelius’s home state of Kansas. It’s more than the net worth of America’s eight largest private foundations. And it’s 33 times the amount of money that Avatar – now the highest-earning movie of all time – has made at the box office.
It doesn’t matter whether you’re covered by Medicare or Medicaid, or by one of the many insurance companies that are victimized by fraud each year. Losses on this scale affect all of us. Fraud isn’t just a drain on the Medicare or Medicaid programs; it drives up the price that all Americans must pay for health care.

The enormity of the health care fraud problem is equaled only by the audacity of some of the fraud schemes that we are confronting. To take a recent example, last week, the Department of Justice settled False Claims Act allegations against a dental management company that was operating nearly 70 clinics across the country. These "Small Smiles Centers" served young children in predominately low-income areas. But instead of treating kids, this company was exploiting them to siphon millions of dollars from Medicaid. Many of these centers performed unnecessary and often painful dental procedures on unsuspecting, helpless children. In some cases, parents were told that healthy teeth needed to be removed. For putting profits above patient safety, this company will pay a $24 million fine, plus interest. And we are continuing to investigate the individual dentists who participated in this scheme.

In another recent case, the Justice Department secured a $10 million consent judgment against two former hospital executives in Los Angeles who scammed our Medicare system by preying upon homeless people. Through kickbacks and coercion, these fraudsters were turning homeless people into hospital patients. Until we caught up with them and shut them down, they were charging Medicare for treatments these patients didn’t receive, didn’t request or didn’t need.
These cases, and countless other successful civil and criminal enforcement actions just like them, are proof that our collaborative efforts are working. We are striking a blow against fraud schemes across the country and, in so doing, are sending a clear message that health care fraud will not be tolerated.
So where do we go from here?

First, we must strengthen HEAT. We will continue to combine and leverage our agencies’ resources and expertise, including the FBI and the Office of Inspector General at HHS, to prevent and prosecute fraud. HEAT will continue to work closely with local U.S. Attorneys Offices to pursue both civil and criminal cases. And in bringing these fraudsters to justice, we will use the power of the Internet and the media to inform the public and the health care industry about how to prevent future fraud schemes.
Second, we’ll continue to support our Medicare Fraud Strike Forces and work to expand these teams to areas of the country where our efforts are most needed. These teams have changed the enforcement landscape. They’ve also demonstrated that, in the area of health care fraud, we must continue to think outside the box and pursue innovative investigative and prosecutorial strategies.

Third, we will continue to push for the investments necessary to meet our duties and do our jobs. I’m pleased that Congress and the Administration have provided strong support. In FY2010, the Administration’s fraud-fighting budget will increase from nearly $200 million to more than $300 million. This may seem like a lot of money – and it is. But I assure you that it’s a sound and prudent investment. For every dollar we spend combating health care fraud, we’re able to return four dollars to the U.S. Treasury and the American taxpayers.

Fourth, our agencies will continue to work with Congress to identify and pursue the legislative and regulatory reforms necessary to prevent, deter and prosecute health care fraud. These reforms range from removing barriers that impede information-sharing to increasing sanctions and penalties.
Finally, t he department will continue to engage the private sector in our anti-fraud efforts. We’ll seek out guidance from representatives of the insurance industry and in the health care-provider community, many of whom are here with us today. We know that the vast majority of those who work in the health care industry are honest people who want to help patients and follow the law. But we also know that a few bad actors have created an industry-wide problem. You all have a critical role to play in helping us to encourage good behavior, bring waste and abuse to light, and hold criminals accountable.
So long as health care fraud pays and these crimes go unpunished, our health care system will remain under siege. These crimes harm all of us – government agencies and programs, industries and individuals. But, through HEAT and with your support, we are fighting back. We welcome and need your help in this shared enterprise.

Your presence here today gives me great hope about our prospects for progress. I’m optimistic about what we can accomplish together, and I look forward to working with you all.

Thank you.

The BIOCLAIM™ Solution

So far, the public awareness, or rather the public concern, in Medicaid fraud, let alone Medicaid fraud in child welfare has been dearth. Little or nothing comes up in the media acknowledging this issue even exists. The most I have come across is a policy position from the White House and a Wall Street Journal article.

Then there are state audits all over the nation identifying fraud.

It is such a simple task for one to stand and call out a problem, but such a grand endeavor to create a solution and present it.

Michigan Senators have sadly attempted to generate a solution to Medicaid fraud in child welfare. The policy offering was so embarrassingly pathetic, it has become a billboard announcement that the state is not doing what it receives federal funding for.

Then, I found logic in a viable solution that is feasible.

The U.S. patented devices and process is called BIOCLAIM™.

Without providing a lecture on biometric technology, I will cut to the chase and provide an except from the website:

The problem is healthcare fraud. Phantom billing, up-coding, card swapping and medical identity theft are the most pervasive types of fraud resulting in estimated losses between 60-220 billion dollars per year.

Other biometric and smartcard company products do not offer a complete solution to healthcare fraud. Most products rely on the front desk to stop a fraudulent transaction. BIOCLAIM™ removes the reliance on the people who are often part of the fraud and creates an auditable technological record.

BIOCLAIM™ is the solution to healthcare fraud.

BIOCLAIM™ is a comprehensive solution to healthcare fraud.

It was at this point I was brought to my knees in the brilliance of the the perfect solution to Medicaid fraud in Child Welfare.

Up until this point, there has been no possible way of conducting a proper audit or examination of the child welfare industry for the following, very simple reasons:

(1) Any matter dealing with a child is protected, or rather excluded and exempted, under Freedom of Information Act statutes. These matters extend from the actual child's identity to the administrative and fiscal operations of a child welfare agency.

BIOCLAIM™ SOLUTION: Each child is assigned an unique coded identifier as is each individual rendering service. Data can be aggregated in time intervals, geographically stratified, just to name a few quantitative methods, to examine the internal operations of a child welfare agency.

(2) Non-profits, 501(c)3's or "That which operates in the name of God" for example, even though they are regulated by the state through licensing, are not audited and are not subject to full disclosure in reporting on 990s nor are these organizations obligated to generate annual reports. In short, there is no Continuous Quality Improvement (CQI) nor is there universal language or policy in operations.

BIOCLAIM™ SOLUTION: The reports could be automatically generate from data, automatically providing transparency, better allowing accountability.

(3) The privatization of child welfare has given birth to the infectious growth called Medicaid fraud. These are Quasi-Governmental-Organizaions (QGOs). Privatization has made it virtually impossible for states to contractually debar, sanction, or revoke licensing due to the inherent conflict of interest of executing the policy of the state. QGOs operate within the woven layers of immunity. This means it is difficult for the state to prosecute itself and this is why the States Medicaid Fraud Control Units do not go after, or even attempt to go after, Medicaid fraud in Child Welfare.

BIOCLAIM™ SOLUTION: Constructing and running specialized reports for States Attorney General to aggressively go after Medicaid fraud in Child Welfare would increase States Federal Funding Percentages, the recoveries could become beneficial to General Funds, and removes the inherent conflict of interest.

(4) Medicaid fraud is so perniciously pervasive that States, and Federal entities, lack the resources and sophistication to stop Medicaid fraud, let alone Medicaid fraud in child welfare.


BIOCLAIM™ SOLUTION: Fraud deterrence would pay for itself through an increase in effective and efficient services. Consumers, or to be more specific, children and guardians will have, for the first time in the history of the child welfare system, an opportunity to file a grievance and have it investigated.

BIOCLAIM™ may be be viewed as an empowering democratic tool as it allows the public, and the consumers of child welfare, to be watchdogs with a voice, furthering the end of Medicaid fraud in child welfare.

My fascination with the idea of biometrics being applied to aberrant billing in child welfare will lead me to investigate this cutting-edge technology as it is symbiotic with my work in AI, which I may present in my next post.