new federal bureau of investigation hlthc f dhealth care...
TRANSCRIPT
Federal Bureau of InvestigationFederal Bureau of InvestigationH lth C F dH lth C F dHealth Care FraudHealth Care Fraud
Special Agent Leah C. WynnSpecial Agent Leah C. WynnNorfolk Division, FBINorfolk Division, FBI
Special Agent Leah C. WynnSpecial Agent Leah C. WynnNorfolk Division, FBINorfolk Division, FBI
What will be coveredWhat will be coveredWhat will be covered….What will be covered….
HCF OverviewHCF OverviewTrendsTrendsTrendsTrendsCasesCasesPredictionsPredictionsPredictionsPredictionsQuestionsQuestions
WHY IS HEALTH CARE FRAUD WHY IS HEALTH CARE FRAUD SO IMPORTANT?SO IMPORTANT?SO IMPORTANT?SO IMPORTANT?
2007: $2.2 Trillion in health care spending2007: $2.2 Trillion in health care spending
But……its not just about dollars and But……its not just about dollars and cents…..many of the schemes put the cents…..many of the schemes put the public at riskpublic at risk
Mission of the FBIMission of the FBIH l h C F d PH l h C F d PHealth Care Fraud ProgramHealth Care Fraud Program
To identify, investigate, and assist in the To identify, investigate, and assist in the prosecution of individuals and entities which:prosecution of individuals and entities which:prosecution of individuals and entities which:prosecution of individuals and entities which:
Defraud US Government Health Care ProgramsDefraud US Government Health Care ProgramsDefraud US Government Health Care ProgramsDefraud US Government Health Care ProgramsDefraud Private Health Care Insurers & ProgramsDefraud Private Health Care Insurers & ProgramsDefraud Consumers of Health Care Programs and Defraud Consumers of Health Care Programs and Health Care ProvidersHealth Care Providers
Health Care FraudHealth Care FraudCriminal StatutesCriminal Statutes
18 USC 134718 USC 1347 -- engage in a scheme or artifice engage in a scheme or artifice to defraud a HC benefit programto defraud a HC benefit programp gp g
18 USC 103518 USC 1035 -- false statements relating to a false statements relating to a HC Benefit ProgramHC Benefit ProgramHC Benefit ProgramHC Benefit Program
18 USC 66918 USC 669 -- theft or embezzlement in theft or embezzlement in connection with a HC Benefit Programconnection with a HC Benefit Programconnection with a HC Benefit Programconnection with a HC Benefit Program
42 USC 1320a42 USC 1320a--7b7b -- antianti--kickback actkickback act
42 USC 1320d42 USC 1320d--66 –– HIPAA medical privacyHIPAA medical privacy
WHERE DOES THE FBIWHERE DOES THE FBIGET INFORMATION?GET INFORMATION?
ComplaintsComplaintsWitnessesWitnessesWitnessesWitnessesData analysisData analysisCurrent / former industry employeesCurrent / former industry employeesCurrent / former industry employeesCurrent / former industry employeesTask ForcesTask ForcesReferralsReferralsReferralsReferrals
SchemesSchemesServices not renderedServices not renderedServices not necessaryServices not necessaryServices not necessaryServices not necessaryKickbacksKickbacksUpcodingUpcodingp gp gUnbundlingUnbundlingProduct substitutionProduct substitutionC t t f dC t t f dCost report fraudCost report fraudSubstandard productsSubstandard productsIllegal Internet prescription drug salesIllegal Internet prescription drug salesega te et p esc pt o d ug sa esega te et p esc pt o d ug sa esPrescription drug diversionPrescription drug diversionCounterfeit pharmaceuticalsCounterfeit pharmaceuticalsMedical privacyMedical privacy
TYPESTYPES
HOME HEALTH CARECLINICSCLINICSCLINICSCLINICS
TYPESOF
TYPESOFAMBULANCE SERVICES
PHARMACYPHARMACYPHARMACYPHARMACY
F R A U DF R A U D
BILLING FRAUDHOSPITALHOSPITALHOSPITALHOSPITAL
F R A U DF R A U D
DME PHYSICIANSLABORATORY FRAUDS
HCF TRENDSHCF TRENDSHCF TRENDS HCF TRENDS
Pain ManagementPain ManagementMedical Identity TheftMedical Identity TheftMedical Identity TheftMedical Identity TheftStaged Auto AccidentsStaged Auto AccidentsHIPAA M di l P iHIPAA M di l P iHIPAA Medical PrivacyHIPAA Medical Privacy
PAIN MANAGEMENTPAIN MANAGEMENTPAIN MANAGEMENTPAIN MANAGEMENTPAIN MANAGEMENTPAIN MANAGEMENTPAIN MANAGEMENTPAIN MANAGEMENT
US v MartinezUS v MartinezUS v. MartinezUS v. MartinezCleveland, OhioCleveland, Ohio
Procedural based pain managementProcedural based pain management
Narcotics for injections tradeNarcotics for injections trade
Patient DeathsPatient Deaths
$59 Million billed to Medicare, Medicaid, OBWC, etc.$59 Million billed to Medicare, Medicaid, OBWC, etc.
Covert investigationCovert investigation
Fi lif f HCF R l i i D h (18Fi lif f HCF R l i i D h (18First life sentence for HCF Resulting in Death (18 First life sentence for HCF Resulting in Death (18 USC 1347)USC 1347)
SOUTHERN CALIFORNIASOUTHERN CALIFORNIAOUTPATIENT SURGERYOUTPATIENT SURGERYOUTPATIENT SURGERY OUTPATIENT SURGERY
CENTER FRAUDCENTER FRAUD
scheme involved private insurancescheme involved private insurance beneficiaries receiving unnecessary surgeries
patients were recruited on a national levelp
losses to insurance industry estimated atlosses to insurance industry estimated atlosses to insurance industry estimated at losses to insurance industry estimated at $800 million$800 million
Prescription DrugsPrescription DrugsPrescription DrugsPrescription Drugs
Yesterday’s Yesterday’s drug dealers drug dealers
are now are now CommittingCommitting
today’s today’s healthhealth--care care
fraud fraud
Obtaining prescriptionsObtaining prescriptionsObtaining prescriptionsObtaining prescriptions
Illicit drugs vs. prescription Illicit drugs vs. prescription drugsdrugs
One ounce of marijuana One ounce of marijuana costs roughly $20 but one costs roughly $20 but one
80 illi ill f80 illi ill f80 milligram pill of 80 milligram pill of oxycontin is worth $80. If oxycontin is worth $80. If a script is for 30 pills, that a script is for 30 pills, that
h t t l fh t t l fhas a street value of has a street value of $2,400!$2,400!
INTERNET PHARMACY CASESINTERNET PHARMACY CASESINTERNET PHARMACY CASESINTERNET PHARMACY CASES
Drug Dealing
Risk to Public
International
United States v. BansalUnited States v. BansalUnited States v. BansalUnited States v. Bansal
Tr e joint in estigation FBI DEA FDATr e joint in estigation FBI DEA FDATrue joint investigation – FBI, DEA, FDA, HHS, IRS, Postal, State and localTrue joint investigation – FBI, DEA, FDA, HHS, IRS, Postal, State and local
Involved 20 subjects operating multiple internet pharmacy websites selling Involved 20 subjects operating multiple internet pharmacy websites selling p y gpharmaceutical drugs without a prescription
p y gpharmaceutical drugs without a prescription
Distributed schedule II, III, and IV drugsDistributed schedule II, III, and IV drugs
AKHIL BANSAL BRIJ BANSAL
BANSAL ORGANIZATION
ANDREW SHACKLETON
MAY 2004MAY 2004
“It looks like they bought theIt looks like they bought the “legitimacy” of our business,
t th f****** b k fpat me on the f****** back for that one.”
-- May 9, 2004 eMay 9, 2004 e--mail from Germein to mail from Germein to -- May 9, 2004 eMay 9, 2004 e--mail from Germein to mail from Germein to yyShackleton regarding an inquiry about Shackleton regarding an inquiry about whether the company was licensed to whether the company was licensed to sell prescription drugs onlinesell prescription drugs online
yyShackleton regarding an inquiry about Shackleton regarding an inquiry about whether the company was licensed to whether the company was licensed to sell prescription drugs onlinesell prescription drugs onlinesell prescription drugs online.sell prescription drugs online.sell prescription drugs online.sell prescription drugs online.
April 17 2006April 17 2006April 17, 2006April 17, 2006
CASE RESULTSCASE RESULTSCASE RESULTSCASE RESULTS20 subjects indicted:20 subjects indicted:
distributing controlled substances without a prescriptionintroducing misbranded drugs into interstate commercemoney laundering
All Subjects Convicted (except Australians not subject to extradition)
The SchemeThe SchemeThe SchemeThe SchemeOrdered 1,000 Rx formsOrdered 1,000 Rx forms,,Used names and DEA # of Used names and DEA # of 23 doctors23 doctorsAdvertised on internetAdvertised on internetCharged consult and Charged consult and
i ti fi ti fprescription feeprescription fee4,000 pills in 44,000 pills in 4--6 weeks6 weeks1 doc’s name used 2501 doc’s name used 2501 doc s name used 250 1 doc s name used 250 timestimes
U S vs StowellU S vs StowellU.S. vs. StowellU.S. vs. Stowell•• Licensed 1970Licensed 1970•• Addiction Medicine Addiction Medicine
and Psychiatryand Psychiatry•• Numerous disciplinary Numerous disciplinary
actionsactionsC i t d b FBI iC i t d b FBI i•• Convicted by FBI in Convicted by FBI in 1994 for HCF under1994 for HCF underthe name of “Rthe name of “Rthe name of R. the name of R. Jeremy Stowell”Jeremy Stowell”
The SchemeThe SchemeThe SchemeThe Scheme
Prior criminal history doc “sneaks” backPrior criminal history doc “sneaks” backPrior criminal history, doc sneaks back Prior criminal history, doc sneaks back into Medicaid programinto Medicaid programWrites prescriptions for known drugWrites prescriptions for known drugWrites prescriptions for known drug Writes prescriptions for known drug addicts addicts Gi i ti t id fGi i ti t id fGives prescriptions outside of Gives prescriptions outside of doctor/patient relationshipdoctor/patient relationship
Conclusion of CaseConclusion of CaseConclusion of CaseConclusion of Case
Plea AgreementPlea AgreementPlea AgreementPlea AgreementHealth Care Fraud (Title 18 USC 1347)Health Care Fraud (Title 18 USC 1347)Distribution of Drugs (Title 21 USC 841)Distribution of Drugs (Title 21 USC 841)Distribution of Drugs (Title 21 USC 841)Distribution of Drugs (Title 21 USC 841)
S t d 3 5 d tit tiS t d 3 5 d tit tiSentenced 3.5 years and restitutionSentenced 3.5 years and restitution
HIPPAHIPPA
Health Insurance Portability and Health Insurance Portability and A t bilit A t f 1996A t bilit A t f 1996Accountability Act of 1996Accountability Act of 1996
Public law 104Public law 104--191 Enacted August 21, 1996191 Enacted August 21, 1996
The Privacy Rule The Privacy Rule The Privacy Rule The Privacy Rule yyaddresses the use and addresses the use and disclosure of disclosure of
yyaddresses the use and addresses the use and disclosure of disclosure of individuals health individuals health informationinformationindividuals health individuals health informationinformation
Health Insurance Portability and Health Insurance Portability and A t bilit A t f 1996A t bilit A t f 1996Accountability Act of 1996Accountability Act of 1996
Public law 104Public law 104--191 Enacted August 21, 1996191 Enacted August 21, 1996
Appropriated $548 Appropriated $548 million to the FBI first 7 million to the FBI first 7 Appropriated $548 Appropriated $548 million to the FBI first 7 million to the FBI first 7 million to the FBI first 7 million to the FBI first 7 years and $114 million years and $114 million each year thereafter) for each year thereafter) for
million to the FBI first 7 million to the FBI first 7 years and $114 million years and $114 million each year thereafter) for each year thereafter) for each year thereafter) for each year thereafter) for health care fraud health care fraud enforcementenforcement
each year thereafter) for each year thereafter) for health care fraud health care fraud enforcementenforcementenforcementenforcementenforcementenforcement
Health Insurance Portability and Health Insurance Portability and A t bilit A t f 1996A t bilit A t f 1996Accountability Act of 1996Accountability Act of 1996
Public law 104Public law 104--191 Enacted August 21, 1996191 Enacted August 21, 1996
Creates and defines a Creates and defines a "FEDERAL HEALTH "FEDERAL HEALTH
Creates and defines a Creates and defines a "FEDERAL HEALTH "FEDERAL HEALTH "FEDERAL HEALTH "FEDERAL HEALTH CARE OFFENSE" CARE OFFENSE"
li bl t b th li bl t b th
"FEDERAL HEALTH "FEDERAL HEALTH CARE OFFENSE" CARE OFFENSE"
li bl t b th li bl t b th applicable to both applicable to both government sponsored government sponsored
d i t h lth d i t h lth
applicable to both applicable to both government sponsored government sponsored
d i t h lth d i t h lth and private health and private health insurance programsinsurance programsand private health and private health insurance programsinsurance programs
Title 18 USC 1347Title 18 USC 1347Title 18 USC 1347Title 18 USC 1347Whoever knowingly and willfully executes, or Whoever knowingly and willfully executes, or
attempts to execute a scheme or artificeattempts to execute a scheme or artificeattempts to execute, a scheme or artifice attempts to execute, a scheme or artifice ––(1) to defraud ANY health care benefit (1) to defraud ANY health care benefit
program; orprogram; orprogram; orprogram; or(2) to obtain, by means of false or fraudulent(2) to obtain, by means of false or fraudulent
pretenses representations or promises anypretenses representations or promises anypretenses, representations, or promises, anypretenses, representations, or promises, anyof the money or property owned by, or of the money or property owned by, or
d th t d t l f ANY h lthd th t d t l f ANY h lthunder the custody or control of, ANY health under the custody or control of, ANY health care benefit programcare benefit program
HIPAA Medical PrivacyHIPAA Medical PrivacyHIPAA Medical PrivacyHIPAA Medical PrivacyUS v. RamirezUS v. Ramirez
Clinic employee sold Clinic employee sold information of FBI Agentinformation of FBI Agent
US v. LewisUS v. LewisM di l t ti lM di l t ti lMedical testing employee Medical testing employee provided a list of law provided a list of law enforcement patient names to enforcement patient names to ppa methamphetamine dealera methamphetamine dealer
FBI Subject caught on cameraFBI Subject caught on cameraFBI Subject caught on cameraFBI Subject caught on camera
Seattle Division subject, a lab technician, was sentenced to 16 months and $9,000 restitution after being convicted of a HIPPA violation.
Medical Identity TheftMedical Identity TheftMedical Identity TheftMedical Identity TheftIdentities stolen by providers to Identities stolen by providers to meet regulatory requirements;meet regulatory requirements;meet regulatory requirements;meet regulatory requirements;
Identities stolen by providers to Identities stolen by providers to submit fraudulent claims;submit fraudulent claims;submit fraudulent claims;submit fraudulent claims;
Identities stolen by individuals Identities stolen by individuals to obtainto obtainto obtain to obtain treatment/prescriptions;treatment/prescriptions;
Identities stolen by individuals Identities stolen by individuals de t t es sto e by d dua sde t t es sto e by d dua sto submit staged auto accident to submit staged auto accident claimsclaims
Using Identities to Using Identities to Ob i TOb i TObtain TreatmentObtain Treatment
By a “crooked” patientBy a “crooked” patient(Maybe the patient is uninsured)(Maybe the patient is uninsured)
Medical ID Theft accounts for Medical ID Theft accounts for 3% f Id tit Th ft C i3% f Id tit Th ft C i3% of Identity Theft Crimes3% of Identity Theft Crimes
2005 study by the Federal Trade Commission2005 study by the Federal Trade Commission
Matthew WisemanMatthew WisemanBeach nurse charged with stealing dead man's credit cardBy Aaron ApplegateBy Aaron ApplegateThe Virginian-Pilot© April 2, 2008
Michael Puopolo was found slumped over in his car in the parking lot of a BJ's Wholesale Club last week. He was pronounced dead at Sentara Bayside Hospital.Six hours later a man in hospital scrubs used Puopolo'sSix hours later, a man in hospital scrubs used Puopolo s credit card at Best Buy to purchase a laptop computer, police said.On Tuesday, police arrested a Sentara Bayside nurse
d h d hi i h h i M h J Wiand charged him with the crime. Matthew J. Wiseman, 24, is facing one count of credit card theft and one count of credit card fraud, both felonies. He was working in the emergency room when Puopolo arrived,working in the emergency room when Puopolo arrived, police said.
United States vs Deborah LovingUnited States vs Deborah LovingUnited States vs. Deborah LovingUnited States vs. Deborah Loving
Company AuditedCompany AuditedCompany AuditedCompany Audited
Owner CreatedOwner CreatedOwner Created Owner Created Fictitious NurseFictitious Nurse
Used information from Used information from another’s application another’s application a o e s app ca oa o e s app ca oand job resume’and job resume’
Submitting Fraudulent ClaimsSubmitting Fraudulent ClaimsSubmitting Fraudulent ClaimsSubmitting Fraudulent Claims
Phantom patientsPhantom patients ––Phantom patients Phantom patients Provider steals an Provider steals an identity to submit identity to submit claims without claims without patient/client’s patient/client’s k l dk l dknowledgeknowledge
Billi f hBilli f hBilling for the Billing for the deceaseddeceased
United States vs. Robert LeaheyUnited States vs. Robert Leaheydba Xtra Care Home Assisteddba Xtra Care Home Assisteddba Xtra Care Home Assisted dba Xtra Care Home Assisted
LivingLiving
St d A t A id tSt d A t A id tStaged Auto AccidentsStaged Auto Accidents
STEALS VIN
JASON THOMPSONAKA WALTER THOMPSONSTOLEN VIN
SCHEME
1997 BUICK LESABREREGISTERED TO NOVA RESIDENT
VICTIM
to Santino Thompson
ALLSTATE INSURANCE POLICY
BART'S CAR STOREANDERSON INDIANA
PROGRESSIVE INSURANCE POLICY GEICO POLICY
2002 Lincoln LSclaimant vehicle
MICHAEL NICHOLAS Claim12/27/2004
paid $3,285.84
MICHAEL NICHOLAS Claim12/27/2004
paid $2,798.18
ROBERT LASKY Claim01/03/2005
paid $3,929.41
Print on paper
MATCHES PRINT OF
handled by Allstate claimant, Roddale
FitzpatrickMATCHES PRINT OF
MARCUS ANTHONY ROBERTSON, JR.
WHAT DOES THE FUTURE WHAT DOES THE FUTURE HOLD?HOLD?
More demand for data analysisMore demand for data analysisMore cyber issuesMore cyber issuesMore Medicaid investigationsMore Medicaid investigationsOrganized crimeOrganized crimeInternational factorsInternational factorsMedicare Part D investigationsMedicare Part D investigationsIdentity / data theftIdentity / data theftIdentity / data theftIdentity / data theft
Report Medical Identity TheftReport Medical Identity TheftReport Medical Identity TheftReport Medical Identity Theft
http://www.hhs.gov/ocr/privacyhowtofile.htmhttp://www.hhs.gov/ocr/privacyhowtofile.htmhttp://www.hhs.gov/ocr/privacyhowtofile.htm http://www.hhs.gov/ocr/privacyhowtofile.htm or 1or 1--800800--368368--1019 for the Office of Civil Rights 1019 for the Office of Civil Rights at the Department of Health and Human at the Department of Health and Human ppServices.Services.http://www.fbi.gov for your local FBI Field Office. http://www.fbi.gov for your local FBI Field Office. p g yp g y(757) 455(757) 455--2546 for the Norfolk Division.2546 for the Norfolk Division.http://www.consumer.gov/idtheft/ or 1http://www.consumer.gov/idtheft/ or 1--877877--IDTHEFT (438IDTHEFT (438--4338) for the Federal Trade 4338) for the Federal Trade Commission.Commission.
