Will the HHS Release of the Medicare Treasure Trove Lead to More Healthcare Fraud Lawsuits?

Will the HHS Release of the Medicare Treasure Trove Lead to More Healthcare Fraud Lawsuits? Will the HHS Release of the Medicare Treasure Trove Lead to More Healthcare Fraud Lawsuits? Will the HHS Release of the Medicare Treasure Trove Lead to More Healthcare Fraud Lawsuits? Will the HHS Release of the Medicare Treasure Trove Lead to More Healthcare Fraud Lawsuits? It's likely. Reuters reports that attorneys specializing in whistleblower healthcare fraud cases are mining the data for clues about potential fraud.

Using data mining techniques to find fraud is not new. The Medicare Fraud Strike Force has been using these analysis techniques - along with trend evaluation and modeling - for some time. During a speech
at the Los Angeles Health Care Fraud Prevention Summit in 2010, for example, Lanny A. Breuer, Assistant Attorney General for the Criminal Division, told the audience that:
In 2007, the Criminal Division of the Justice Department refocused our approach to investigating and prosecuting health care fraud cases. Our investigative approach is now data driven: put simply, our analysts and agents review Medicare billing data from across the country; identify patterns of unusual billing conduct; and then deploy our "Strike Force" teams of investigators and prosecutors to those hotspots to investigate, make arrests, and prosecute. And as criminals become more creative and sophisticated, we intend to use our most aggressive investigative techniques to be right at their heels. Whenever possible, we actively use undercover operations, court-authorized wiretaps and room bugs, and confidential informants to stop these schemes in their tracks.[1]
And the big data analysis techniques are working. In 2012, several individuals allegedly involved in a $375 million home health fraud scheme were indicted in the Northern District of Texas. HHS Inspector General Daniel Levinson commented that they were discovered by the use of "data analysis [allowing the investigators to] target suspicious billing spikes." Levinson explained that, “[i]n this case, our analysts discovered that in 2010, while 99 percent of physicians who certified patients for home health signed off on 104 or fewer people Dr. Roy certified more than 5,000."[2]

But, with the release of the Medicare billing data to the public, now plaintiffs' lawyers have access to the data as well. Given the possible recoveries, it's no surprise:
A whistleblower who prevails gets up to 30 percent of whatever the government recovers, and 40 percent of that reward typically goes to the whistleblower's lawyer.

Whistleblower cases can result in huge settlements, such as the $3 billion GlaxoSmithKline paid in 2012 to resolve claims that it promoted drugs for unapproved uses and failed to report certain safety data.[3]

As explained by Reuters, the whistleblower lawyers are doing the same thing that the government is doing in it's analysis - looking for doctors whose billing practices are outside the norm to bolster existing cases:
By Thursday, Pennsylvania lawyer Marc Raspanti was having a ball. Raspanti said he spent six hours combing through the data. He has several Medicare fraud lawsuits pending against pharmaceutical companies alleging kickbacks to certain doctors.

Raspanti is analyzing the data, he said, to see if doctors are prescribing an unusually high amount of the pharmaceutical company's products. If so, he said, that could bolster allegations that something is amiss.
In undertaking this analysis, however, attorneys are likely find new cases. Additionally, practice managers, pharmaceutical sales managers, nurse practitioners, and others who have a suspicion that something may be amiss in a practice, with their employer, with a pharmaceutical relationship, can now themselves use the database to investigate. This data release will likely lead to additional healthcare fraud cases and bolster whistleblower claims.

[1] Press Release, Department of Justice, Assistant Attorney General for the Criminal Division Lanny A. Breuer Speaks at the Los Angeles Health Care Fraud Prevention Summit, Speech, Aug. 26, 2010, available at https://www.justice.gov/criminal/pr/speeches/2010/crm-speech-100826.html (last visited April 19, 2014).

[2] Press Release, Department of Justice, Dallas Doctor Arrested for Alleged Role in Nearly $375 Million Health Care Fraud Scheme, Feb. 28, 2012, available at https://www.justice.gov/opa/pr/2012/February/12-crm-260.html
(last visited April 19, 2014).

[3] Terry Baynes, Lawyers Start Mining the Medicare Data for Clues to Fraud, Reuters, April 14, 2014, https://www.reuters.com/article/2014/04/14/us-data-idUSBREA3D05820140414.

[4] Id.

Posted by Tatiana Melnik April 19, 2014.

November 2016

Blog Home  

Newest Blog Entries
7/23/15 Hospital Settles with OCR for $ 218,400 Over Cloud-Based File Sharing

6/8/15 Two California Privacy Bills to Watch in 2015

3/28/15 When Looking at Security, Consider Every Device

3/9/15 Alabama Board of Optometry Makes Final a Rule on Telemedicine

1/25/15 Indiana Court of Appeals Upholds $1.44 Million Jury Verdict Against Walgreen Co. in a Privacy Breach Case; Denies Rehearing

12/9/14 Malware Leads to a $150,000 OCR Settlement with a Behavioral Health Provider

11/30/14 Can a Board of Medicine Use the State’s Prescription Drug Database in Investigating Physician Actions?

11/29/14 Under the Florida Telemedicine Rule, Can a Physical be Conducted by Telemedicine?

11/19/14 Wearables and the Challenge for Consumer Device Makers

10/28/14 A Few Telemedicine Resources

10/27/14 FCC: The Newest Regulator to Throw its Hat into the Data Privacy and Security Ring

Blog Archives
April 2014 (6)
February 2014 (4)
May 2014 (6)
November 2014 (3)
July 2014 (1)
June 2015 (1)
November 2013 (3)
September 2014 (1)
December 2014 (1)
January 2015 (1)
June 2014 (3)
December 2013 (5)
March 2015 (2)
October 2013 (9)
July 2015 (1)
October 2014 (2)
March 2014 (3)
August 2014 (4)
January 2014 (4)

Blog Labels
Dental (1)
FCC (1)
Financial Services (1)
Mobile Apps (2)
Medical Marijuana (1)
Employment (1)
FAQ (6)
Meaningful Use (4)
EHR (2)
Privacy Litigation (3)
Identity Theft (1)
Security (1)
Healthcare Fraud (1)
Marketing (1)
BYOD (2)
Social Media (2)
Mobile Apps FDA (2)
Data Breach (10)
Big Data (3)
Healthcare Competition (1)
Privacy (4)
Telemedicine (7)