It takes a village to defraud the government

Congress twists and turns in its collective seat figuring out what to do about a growing stain of opioid addition. The Wall Street Journal reports, a big-time (as in big-dollar) tort lawyer wants to sue the opioid manufacturers for billions and billions, just like he and a tribe of cohorts took on tobacco.

Yet, consider this: One in three Medicare Part D beneficiaries received a prescription opioid in 2016. Half a million people received high amounts of opioids, with 90,000 at serious risk. Who says? The Health and Human Services inspector general.

So is Medicare itself unwittingly complicit in the opioid addition epidemic? Hard to say, but Medicare fraud is a contributing factor. From the fact sheet of its 2017 National Health Care Fraud Takedown, we learn of one Texas  “medical professional” charged with deliberately over-subscribing opioids. Some patients died. The doctor received $1.2 million in Medicare reimbursement — fraudulently, the IG says.

Tom O'Donnell, ‎Assistant Inspector General for Investigations, HHS - July 24, 2017

Opioids provide just one avenue of fraud. The 400 defendants include rings of doctors and nurses who engaged in kickbacks and medically unnecessary billings for joint injections, drug screenings and home health services. Still, opioid prescription abuse accounted for 295 of the defendants — including 57 doctors, 162 nurses and 36 pharmacists.

In all, the IG and its federal and state law enforcement partners allege $1.3 billion worth of fraud in the Takedown.

If they nabbed those 400, it makes you wonder how extensive the problem really is.

Very, in the opinion of the assistant HHS inspector general for investigations, Tom O’Donnell. In my interview, he said these annual Takedowns have been taking place since 2010. Between whistleblowers and fraud detection data analytic units at HHS and its large child agency, the Centers for Medicare and Medicaid Services, the IG never has a dearth of fraud patterns to investigate.

Each Takedown requires at least a half a year’s work and multiple law enforcement agencies, plus the federal prosecutors. So in a sense it take a village to take down a major Medicare fraud ring.

O’Donnell says drug fraud — principally opioids — have supplanted durable medical equipment as the fraud thing of choice. Plenty of able bodied people, enabled by their practitioners, are getting electric scooters and wheelchairs. But the action is opioids.

An episode of the Netflix show, “Better Call Saul” depicted a hapless IT nerd at a pharmaceutical company stealing sealed bottles of pills from inventory  and selling them to a shadowy and scary gang figure. The IT guy trades in his dorky minivan for a gigantic and fully-equipped Hummer H2, complete with flame paint job and chrome spinners. Message: There’s real money in this.

A poor schlub living in a fictional Western bungalow and having only his baseball cards for companions makes for the sort of figure you can imaging would indulge in a crime of convenience. What I can’t understand is someone doing what it takes to obtain a medical, nursing or pharmacist degree and choosing the route of Medicare fraud.

Because it takes rings of cohorts of billing specialists, lawyers, accountants and various hangers-on, typically someone loses nerve or gains conscience and blows the whistle. It’ll be a while before the strength of data analytics will become strong enough to provide deterrence.

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