Health Care Fraud
Industry experts estimate annual expenditures for Health Care Fraud [HCF] and abuse total approximately 3 to 15 percent of the total monies expended for healthcare in the United States. Not as dire, the National Healthcare Anti-fraud Association suggests the costs for Health Care Fraud are more likely 3 to 10 percent; while the GAO and the Congressional Budget Office estimate the costs at 10 percent; and, the U.S. Chamber of Commerce says 15 percent.
Using these data bases, in 2014, the costs related to Health Care Fraud and abuse totaled approximately $300–450 billion noting under the Affordable Care Act [ACA] National Health Expenditures amounted to $3.0 trillion.
Under the Health Care Fraud Statue, Title 18, United States Code [USC], Section 1347, any person who knowingly and willfully, or attempts to knowingly or willfully execute a scheme or artifice to defraud any health care benefit program; or obtain, by means of false or fraudulent pretenses, representation, or promises, any money or property owned by, or under the custody or control of any health care benefit program, in connection with the delivery and/or payment for health care benefits, items or services can be prosecuted.
Some of the most common types of Health Care Fraud investigated by Law Enforcement and the FBI are misrepresentation of services using incorrect Current Procedural Terminology (CPT) codes; billing for services not rendered; altering claim forms for higher payments; falsification of information in medical record documents, codes, and treatment histories; billing for services that were not performed or misrepresenting the types of services that were provided; billing for supplies not provided; and providing medical services that are unnecessary based on the patient’s condition.
Setting up the framework to investigate and prosecute Health Care Fraud, it was The Health Insurance Portability and Accountability Act of 1996 [HIPAA] that established a national Health Care Fraud and Abuse Control Program [HCFAC or the Program] under which investigations are authorized under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services [HHS].
In accordance with the aforementioned framework, the FBI is the primary agency responsible for HCF investigations with jurisdiction over both Federal and private health insurance programs. The FBI considers Health Care Fraud a top priority within the FBI’s Complex Financial Crime Program with each of the FBI’s 56 field offices allocated personnel specifically assigned to investigate HCF related matters.
According to the Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2014, issued by The Department of Health and Human Services [HHS] and The Department of Justice [DOJ]:
In FY 2014, the FBI was allocated $127.3 million in HIPAA funding used to support 797 positions (476 Agent, 321 Support). As a result of the funding, the FBI initiated 602 new Health Care Fraud investigations and had 2,771 pending investigations. Investigative results produced 730 criminal Health Care Fraud convictions and 849 Indictments and Informations. Additionally, investigative efforts resulted in more than 605 operational disruptions of criminal fraud organizations and the dismantlement of the criminal hierarchy of more than 140 Health Care Fraud criminal enterprises.
Directory members with a background in Health Care Fraud can be extremely helpful to anyone seeking information and/or requiring a professional opinion pursuing Health Care Fraud related litigation. Looking for an expert and/or an investigator concerning Health Care Fraud—visitors need only use the website’s search feature, entering the appropriate skill and geographical area of preference to locate an FBI specialist, and thereafter make contact, using the information provided.
Retired FBI Agents and Analysts, interested in securing a Directory listing and/or a personal email address, need only submit a brief online application to join the website.
Agents with Health Care Fraud skillset
- Patrick M. Conley
- William J. McShane
- James J Wedick
- Charlotte F. Braziel
- Fred Olivares III
- Joseph J. Pelcher
- Chris J. Quick
- John E. (Jack) Brennan
- Hilary C. Jenkins
- James T. Bagwell - Special Agent
- Thomas W. Raftery III
- Daniel Bellich
- Herbert Cousins, Jr
- Edward J ODonnell
- Joseph R. Lewis
- Jeffrey L. Rinek
- Donald B. Southerland, Jr.
- Kevin Baker
- George W Murray
- Jeffrey A. Danik
- Bryan Gorczyk
- James K. Ellis, CFE