How are fraud cases identified?
In many cases, the fraud lawsuits come to us from whistleblowers. The beauty is that the False Claims Act allows these relaters, or whistleblowers, to participate by filing a case and collecting up to a possible 25 percent of the settlement. Some companies do self-report, but it doesn't mean that they're off the hook for paying the government back. The False Claims Act also allows for payment of up to three times the amount of the fraud. Sometimes we discover these cases on our own, but others can be reported by collections agencies such as the Centers for Medicare & Medicaid Services.
Which sectors of healthcare are more likely to see Medicare/Medicaid fraud?
There are cases coming from across the board: Medical practices, hospitals, durable medical equipment companies and pharmaceutical companies. Pharmaceuticals make the biggest splash because it's usually a lot of money. Many doctors have been caught, but the U.S. attorney's office usually pursues smaller cases on a local level and they don't make it to the civil or criminal divisions of the DOJ.
What areas of the country are more susceptible to fraud? Why?
The Criminal Division deals with Medicare Fraud Strike Force teams in seven different high-fraud regions: Miami, Los Angeles, Detroit, Houston, Brooklyn, Tampa and Baton Rouge. These locations contain more cases due to the fact that a larger population provides a better sample of people who are vulnerable and can be coerced into helping commit fraud, usually for kickbacks of some form. It's all about money.
Are there any cases that strike you as significant or interesting?
As far as significant cases go, we've had all the major pharmaceuticals suits come through the civil division, some reaching into the billions of dollars. Pfizer and Lily are two examples. There are so many. Guidant was prosecuted recently. As far as the civil cases go, most are settled out of court. When choosing whether a case is civil or criminal, it is determined at the local level of the U.S. Attorney's office. The memorable cases are usually egregious amounts of fraud.