TUCSON, Ariz., Feb. 21, 2011 /PRNewswire-USNewswire/ -- In what officials call the "largest-ever federal healthcare fraud takedown," 700 federal agents rounded up more than 100 suspects in a nationwide sweep of arrests on Feb 17. Television news showed armed FBI agents in bullet-proof vests hauling off a doctor and staff members in handcuffs.
Such raids are not new. In the past, patients have reportedly been lined up against the wall by agents with unholstered guns, and in one instance a 9-year-old boy had a gun pointed at him in his own home, which was adjacent to his father's office. But the scope is increasing. The new healthcare reform law adds $100,000,000 to the law enforcement budget. Additionally, the burden of proof is lowered—there is no need to prove intent to defraud—and penalties are harsher, as summarized in the fall 2010 issue of the Journal of American Physicians and Surgeons (http://www.jpands.org/vol15no3/orient.pdf).
Seeing a large squad of heavily armed agents, one might think they are expecting to encounter terrorists or drug cartels, and seeking bombs or illicit drugs. Rather, they are seizing medical records to search for evidence of "waste, fraud, and abuse."
While the doctor is accused of behavior that sounds inexcusable, such as "billing for services not provided," the prosecutor may be referring to billing for an extended office visit without documenting the required number of "bullet points," explains Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons (AAPS). What used to be called a mistake or a billing dispute over complex coding requirements is now considered fraud or a false claim. "Unnecessary" tests—by the government's definition—may also be called fraud.
While Medicare may have paid out millions of dollars for fraudulent schemes, "some of the people going to prison are 60-year-old doctors who worked 80-hour weeks serving patients for 30 years," Orient notes. "Their 'crime' consisted of tripping up on ambiguous and complicated billing rules."
Attorney General Eric Holder called the average prison sentence of 43 months "a pretty substantial hit." For a doctor, it is a professional death sentence, Orient points out. He loses his reputation, his livelihood, likely all of his assets, and sometimes his family as well.
As Assistant Attorney General Lanny Breuer states, most of the accused are convicted. Orient explains that the vast majority plead guilty because of the threat of decades in prison if they go to trial. At trial, the deck is heavily stacked against them.
AAPS recommends that physicians never accept payment from government insurance programs. Patients who want to be sure the doctor is working for their best interests rather than slavishly following government rules—and who want to minimize their chance of being in an office that is unjustly targeted by an FBI raid—can find links to opted-out doctors on the AAPS website (www.aapsonline.org).
"If the government seriously wanted to stop Medicare fraud, rather than to swell the prison population with doctors, it would disallow the assignment of benefits," Orient said. "Benefits should be paid to the beneficiary—the patient—not the provider. It would make fraud self-revealing, like credit-card fraud is now."
AAPS, a national organization representing physicians in all specialties, advocates for private medicine, in which the physician is working for the patient, not for the government or another third party.
SOURCE Association of American Physicians and Surgeons (AAPS)