- The DOJ has charged three healthcare professionals with conspiracy, obstruction, money laundering, and healthcare fraud in a Miami-area scheme that bilked Medicare and Medicaid of more than $1 billion over 14 years, officials announced Friday.
- Those charged include the owner of more than 30 Florida skilled nursing and assisted living facilities, a hospital administrator, and a physician’s assistant.
- The case makes history as "the largest single criminal health care fraud case ever brought against individuals by the Department of Justice," stated Assistant Attorney General Leslie R. Caldwell of the Justice Department’s Criminal Division.
The government has touted the successful use of data-driven law enforcement in this case, a key strategy in its hardline approach to fighting against healthcare fraud in general, and in the recent announcement of $42 billion in savings from program integrity efforts.
The FBI and HHS-OIG used advanced data analysis and forensic accounting to uncover the full scope of the scheme, which was investigated under a Medicare Fraud Strike Force team.
The indictment alleges that Philip Esformes, 47, who operated the Esformes Network of more than 30 skilled nursing homes and assisted living facilities, funneled in thousands of beneficiaries unqualified for facility placement, and billed the government for providing medically unnecessary services. It further alleges that Esformes and his co-conspirators took kickbacks from other providers for providing patients with medically unnecessary treatments.
Esformes reportedly faced similar allegations of improperly admitting patients in 2006 and paid $15.4 million to resolve the claims through a civil settlement. Yet he allegedly adapted the scheme with his co-conspirators to continue undetected.
Recently, Venson Wallin, consulting managing director at accounting firm BDO, shared with Healthcare Dive some tips to avoid healthcare fraud. Relating to to healthcare data, he said administrators don’t want to be surprised if the data point to audit records or documentation leading to embarrassing results or banishment from a Medicare program. “You need to know what’s going on in your shop from a data perspective,” Wallin said. There needs to be monitoring and tracking of the billing, claims data.
Unfortunately, management is inundated with data and knowing where to focus oversight, which data to include, how often to look at it, and setting up appropriate monitoring and tracking techniques can prove difficult. It still needs to happen to receive initial compliance issues notices and minimize financial risk, Wallin said.