Fraud, Waste & Abuse
Definition Medicare – Healthcare

Health Care Fraud is #defined as 

 “knowingly and willfully executing, or attempting to execute, a scheme or artifice

• to defraud any health care benefit program; or
• to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health benefit program.” 

Healthcare fraud can result in civil and criminal penalties that include fines, monetary damages, and even imprisonment.  Additionally, there is a penalty of up to 20 years in prison or life in prison if the violation resulted in a person’s death. ^{18 U.S.C. §1347}

Fraud occurs when

someone knowingly lies to obtain some benefit or advantage to which they are not otherwise entitled or someone knowingly denies some benefit that is due and to which someone is entitled.

Waste

Waste includes overusing services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.

Abuse

Abuse includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.  ^{The Medicare Learning Network®}

• What’s  on this page?
  • Risk Adjustment Fraud 
  • HRA Health Risk Assessment Questionnaire
  • Latest Busts
  • Fraud & Premium Increases
  • Medi Cal Medi Caid Fraud
  • Scam Phone Calls?
  • Fraud Defined
    • Fraud Statutes
  • Stop Medicare Fraud Website
  • Money Laundering 

#Latest Busts 

• California investigating Centene over alleged Medicaid fraud Modern Health Care 4.25.2022
• Seven Californians among people charged in $150-million COVID aid fraud scheme LA Times 4.20.2022
• HHS proposes crackdown on fraudulent ACA signups by brokers ^{Benefits Pro 1.2022}
• Mahyar David Yadidi – a San Pedro, California, chiropractor – to prison and ordered him to make restitution for defrauding the International Longshore and Warehouse Union-Pacific Maritime Association (ILWU-PMA) Welfare Plan. The court’s action follows an investigation by the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) and Office of Inspector General (OIG).
• 91 Charged in Federal Health Care Fraud Sting  Kaiser News
• The court sentenced Mahyar David Yadidi – owner of Philips San Pedro Chiropractic – to 46 months in prison and ordered to make $1,976,832 in restitution for defrauding the maritime union welfare plan. ^DOL.gov *
• It’s alleged Adam Hocking created fictitious insurance policies and documents for clients, and accepted payments for the same, when no such policies existed. These actions resulted in Iowa consumers being left uninsured when they attempted to file a claim as a result of a loss. ^{Insurance Journal} *        ^{Charging Complaint on Broker}
• Feds charge hundreds of individuals in $6 billion healthcare fraud
• More than 340 individuals were charged with submitting $6 billion in fraudulent claims to federal healthcare programs and private insurers for telehealth consultations and substance abuse treatment, among other services, the Justice Department announced Wednesday, describing it as the largest healthcare fraud takedown in history.  Modern Health Care *
• Purdue Pharma to plead guilty
  OxyContin maker’s admission won’t end liability for executives or the Sackler family.
• CA Health Line 7.19.2017  Fraud & Billing mistakes in Medicare Advantage plans ran $16B in 2016, if you include standard Medicare $60B.
• Orange County Register: Brea Man Gets Decade In Prison In $2.9 Million Dollar Medicare Fraud  A Brea man who used his rehabilitation clinics to submit millions of dollars in false Medicare claims was sentenced this week to more than a decade in federal prison, even as he awaits sentencing in a second health care fraud case. U.S. District Judge David O. Carter, during a hearing at the federal courthouse in Santa Ana, ordered Simon Hong on Monday to spend 121 months behind bars and to pay nearly $3 million in restitution, according to the U.S. Department of Justice. (Emery, 1/10)
• Aetna wins $37.4 M civil judgement for fraudulent bills from Bay Area Surgical Management  Learn More===>  Mercury News 4.21.2016
• Indictments – a doctor at the clinic documented evaluations that never happened, while staff falsified records to justify surgeries, some of which were unnecessary. Further, the indictment said some surgeries were performed by a physician’s assistant who had not attended medical school and was not overseen by a surgeon during the procedures.  Although the patient victims sustained physical harm, we who pay higher premiums for health care suffer economic harm when scams are allowed to continue unchecked” (Winton/Hamilton, “L.A. Now,” Los Angeles Times, 9/15).   CA Healthline 9.16.2015
• Durable Medical Equipment Fraud – LA Times 9.4.2015
• Nearly 250 people, including 46 providers, were charged with falsely billing Medicare a total of nearly $712 million   –  Medicare Fraud Strike Force, which has charged more than 2,300 people accused of falsely billing Medicare more than $7 billion since it was established in 2007  —
• federal officials charged:
• Three owners of a hospice service in Detroit who allegedly paid kickbacks for referrals from two physicians who wrote medically unnecessary prescriptions;
• Two home health care companies in New Orleans that allegedly billed Medicare $38 million for glucose monitors they sent to patients regardless of medical need; and
• Administrators of a mental health center in Miami that allegedly paid kickbacks to owners of assisted living facilities and patient recruiters (Department of Justice release, 6/18).  ^{CA Health Line 6.19.2015}  
• More than 44 of the 243 suspects allegedly defrauded Medicare Part D, marking the first major crackdown on fraud of the prescription drug benefits program for seniors.
• Fraud investigations – 3.3B recovered in 2014  Learn More ⇒ CA Healthline 3.19.2015
• CA Healthline 12.5.2014 – New rule to allow Medicare to deny payments to providers with a history of abuse