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Health care fraud a growing criminal enterprise

Saturday, Feb. 1, 2014 5:41 PM
Last updated Sunday, Feb. 2, 2014 2:11 AM
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Since March 2007, federal investigators have uncovered more than $5 billion in Medicare fraud, but they suspect that might just be the tip of the iceberg.

Kenneth Crowder (left) and David Stewart recently left the U.S. attorney's office. One of Stewart's duties that the U.S. attorney's office was health care fraud coordinator.  SARA CALDWELL/STAFF
Kenneth Crowder (left) and David Stewart recently left the U.S. attorney's office. One of Stewart's duties that the U.S. attorney's office was health care fraud coordinator.

As the prolific bank robber Willie Sutton reportedly said of robbing banks – because that’s where the money is – health care fraud has become a huge problem throughout the country.

According to the U.S. De­part­ment of Justice, Geor­gia ranks 12th in investigations, seventh in the number of fraud cases and sixth in total recovered – almost $98.95 million in 2012.

In the Southern District of Georgia, more than $27 million in restitution was collected last year in one of the country’s largest Medicare fraud prosecutions in 2005 – The Bio-Med Plus in Savannah.

In Augus­ta, optometrist Jeffrey Spon­sel­ler was sentenced Jan. 9 to 33 months in prison and ordered to pay $441,000 in restitution for bilking Medicare.

Federal investigations into Medicare fraud have exploded in response to the problem, said David Stewart, who recently left the U.S. attorney’s office where one of his duties was health care fraud coordinator.

Medicare fraud affects everyone because Medicare has become the primary health care coverage for most Amer­i­cans when they turn 65, said Ken­neth Crowder, who recently left the U.S. attorney’s office and joined Stewart in private practice.

When Medicare coverage started in 1966, 19.1 million were enrolled. In 2013, that number was 43.5 million, according to the Centers for Medicare and Medicaid Services.

With the last of the baby boomer generation turning 50 this year and increased health insurance coverage through the Affordable Care Act, Stew­art and Crowder said fraud is expected to expand.

Going after health care fraud holds the promise of getting money back for the government, Stewart said, which is another reason the Jus­tice Department has set that as a top goal.

The attack on those defrauding Medicare and military health care provider TriCare occurs in criminal and civil courts. The difference between prosecution and a civil lawsuit is intent, Stewart said. And intent can be difficult to prove.

In the Sponseller case, the defense attorney tried to portray the optometrist’s act as more billing errors than intentional fraud because of the complexity of the Medicare billing process.

But in cases such as Spon­seller’s – who billed for 177, 45-minute comprehensive exams performed in a single day – the intent to defraud becomes clear. The more outrageous cases are the ones that are criminally prosecuted, Stewart said.

In another case from the Sou­thern District, two nutritionists bilked Medicaid of $4 million by billing for services to Head Start programs throughout the state. The intent to defraud became clear when investigators uncovered bank records that proved they were on Florida vacations at the same time they were allegedly visiting Head Start sites, Stewart said.

Crowder, who was the chief of the civil division for the U.S. attorney’s office in the Southern District of Georgia, said that in 10 years the investigation of health care fraud became the largest part of their work.

Special strike forces have been sent to areas deemed as hot beds of Medicare fraud. In May, teams working in eight cities made 89 arrests while uncovering $223 million in fraudulent

The fraud can take the form of medical professionals billing for services they do not perform, or when thieves obtain Medicare billing and patient numbers and create scam operations, Stewart said.

But the government is fighting back. Medicare has contracts with businesses that patrol for fraudulent activity, has established a hot line for whistle-blowers, and has increased the number of investigators who hunt suspected fraud and abuse. Data specialists are now searching for suspicious billing practices in the billions of claims filed every year.

Under the Affordable Care Act, federal investigators and the Justice Depart­ment have new tools to combat fraud and waste, which helps recover more money to put back into the health care system, Stewart said.

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david jennings
david jennings 02/01/14 - 09:48 pm
Little or no cost to you

You hear it on tv. constantly. Companies making cold calls begging people to sign up for "free" no cost to you medical supplies. Why have I known abuse and fraud have existed for years now, and Federal investigators suspect. This coupled with abuse of entitlements is costing taxpayers enormous sums. I just wonder, when will they finally break the working people' back? Got your "hoover round", stair climber?

Graymare 02/01/14 - 10:42 pm
The whole, dang Obama Care

The whole, dang Obama Care mess is health care fraud! "The Fleecing of the American Citizens"

Dixieman 02/02/14 - 07:55 am
I can't resist!

Headline: "Health care fraud a growing criminal enterprise"
Catching the fraudster is a no-brainer! He lives at 1600 Pennsylvania Avenue and his initials are "B.O.".

allhans 02/02/14 - 11:22 am
What about the person who

What about the person who approves payment of these claims. No liability there?

rmwhitley 02/02/14 - 11:33 am

just making it easier.

jimmymac 02/02/14 - 12:33 pm

Much of the fraud is pushed by big farma who convince doc's that their drugs should be pushed. People are getting drugs and merchandise they don't need and wouldn't get if they had to pay themselves. As long as uncle Sugar is paying everyone seems to think it's OK. Learn to question doctors when they prescribe meds and just be honest. Did you really need that Hover Around and would you have got it if you had to pay out of your own pocket?

itsanotherday1 02/02/14 - 12:53 pm
You would never see this

You would never see this level of fraud committed against a private entity, no matter how large.

Just further evidence of the level of incompetence in government.

TrulyWorried 02/02/14 - 01:26 pm
Healthcare fraud

It has existed for a long time, it is just being discussed more, "now". Sad thing is that if a fraud is being reported by someone, and it has been done, it is many times ignored - yes - ignored - one of my family members had a solid case but the folks on the other end of the cord were not interested. Are they somehow involved - get kick backs? One has to wonder!

Sweet son
Sweet son 02/02/14 - 02:49 pm
Too funny!

Statement made in the article: "Under the Affordable Care Act, federal investigators and the Justice Depart­ment have new tools to combat fraud and waste, which helps recover more money to put back into the health care system, Stewart said."

Barry O and friends can't even get the thing off the ground. And Eric Holder and the boys are going to recover money! Give us a break!

saywhatagain 02/02/14 - 05:36 pm

...and you think it's bad now? Wait until Obamacare gets into full bloom!

belle 02/03/14 - 09:00 am
Whatever happened with this one in 2009?

Stamen Medical faces Medicare fraud probe

...the search warrant's affidavit, is suspected of fraud in billing Medicare...

Seems if they were cleared they would have made that public....

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